1114045804 NPI number — STEVEN J URBACK DDS MAGD PS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114045804 NPI number — STEVEN J URBACK DDS MAGD PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVEN J URBACK DDS MAGD PS
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:
PUYALLUP VALLEY DENTAL CARE
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:
1114045804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2921 5TH AVE NE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98372-7044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-841-3173
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2921 5TH AVE NE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-7044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-841-3173
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GIDEON
Authorized Official First Name:
LAUREN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
253-841-3173

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5496 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5047048 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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