1003086174 NPI number — A.T. BASSIRI, D.D.S., P.A.

Table of content: (NPI 1003086174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003086174 NPI number — A.T. BASSIRI, D.D.S., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A.T. BASSIRI, D.D.S., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PINE VALLEY FAMILY DENTISTRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003086174
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1661 OWEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28304-3425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-485-2273
Provider Business Mailing Address Fax Number:
910-485-0772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1661 OWEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-485-2273
Provider Business Practice Location Address Fax Number:
910-485-0772
Provider Enumeration Date:
03/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
INMAN
Authorized Official First Name:
KIRSTEN
Authorized Official Middle Name:
TOI
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
910-425-2273

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  6315 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 767829 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 90477 . This is a "BLUE CROSS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8990477 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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