1417313883 NPI number — PROVIDENCE DENTAL DHILLON PLLC

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 1417313883 NPI number — PROVIDENCE DENTAL DHILLON PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE DENTAL DHILLON PLLC
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:
WEST HENDERSON DENTAL
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:
1417313883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 35145 LB 413169
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-948-6787
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7181 N HUALAPAI WAY
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89166-1115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-349-2420
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LORICK
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
704-806-3632

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  S6-81 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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