1396969093 NPI number — SCHUYLKILL MALL DENTAL

Table of content: MRS. CARRIE MICHELLE BAIRD LPN (NPI 1982857389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396969093 NPI number — SCHUYLKILL MALL DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCHUYLKILL MALL DENTAL
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:
1396969093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
SCHUYLKILL MALL DENTAL
Provider Second Line Business Mailing Address:
ROUTE 61 AT INTERSTATE 81
Provider Business Mailing Address City Name:
FRACKVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-874-3714
Provider Business Mailing Address Fax Number:
570-874-3444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SCHUYLKILL MALL DENTAL
Provider Second Line Business Practice Location Address:
ROUTE 61 AT INTERSTATE 81
Provider Business Practice Location Address City Name:
FRACKVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-874-3714
Provider Business Practice Location Address Fax Number:
570-874-3444
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HISCHE
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-874-3714

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DS024286L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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