1427146364 NPI number — DALE E COLCLASURE SR. DDS

Table of content: DALE E COLCLASURE SR. DDS (NPI 1427146364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427146364 NPI number — DALE E COLCLASURE SR. DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLCLASURE
Provider First Name:
DALE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1427146364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32 RIVER ESTATES COVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-868-5966
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2501 CRESTWOOD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-758-3393
Provider Business Practice Location Address Fax Number:
501-758-4346
Provider Enumeration Date:
10/10/2006

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: 122300000X , with the licence number:  2111 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 58089 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 801533 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com