1194991000 NPI number — PAMELA JEAN ENTORF GDH RDH BS MEPD

Table of content: PAMELA JEAN ENTORF GDH RDH BS MEPD (NPI 1194991000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194991000 NPI number — PAMELA JEAN ENTORF GDH RDH BS MEPD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENTORF
Provider First Name:
PAMELA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
GDH RDH BS MEPD
Provider Gender Code:
F

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:
1194991000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 W CLAIREMONT AVE
Provider Second Line Business Mailing Address:
CHIPPEWA VALLEY TECHNICAL COLLEGE DENTAL HYGIENE PROGRA
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-833-6370
Provider Business Mailing Address Fax Number:
715-833-6447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 W CLAIREMONT AVE
Provider Second Line Business Practice Location Address:
CHIPPEWA VALLEY TECHNICAL COLLEGE DENTAL HYGIENE PROGRA
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-833-6506
Provider Business Practice Location Address Fax Number:
715-833-6447
Provider Enumeration Date:
05/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  3215016 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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