1043463417 NPI number — WEST CENTRAL SMILES PA

Table of content: (NPI 1043463417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043463417 NPI number — WEST CENTRAL SMILES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST CENTRAL SMILES PA
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:
Provider Other Organization Name Type Code:
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:
1043463417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 19TH AVE SW
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
WILLMAR
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56201-5288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 N SIBLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITCHFIELD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55355-1756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-235-3102
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
Authorized Official Title or Position:
DR./CEO
Authorized Official Telephone Number:
320-235-3102

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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