1558357020 NPI number — JAMES R SUEPPEL DDS

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558357020 NPI number — JAMES R SUEPPEL DDS

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

SUEPPEL

Provider First Name:

JAMES

Provider Middle Name:

R

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DDS

Provider Gender Code:

M

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:

1558357020

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/07/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

P.O. BOX 39

Provider Second Line Business Mailing Address:

238 FRONT STREET SCENIC BLUFFS HEALTH CENTER

Provider Business Mailing Address City Name:

CASHTON

Provider Business Mailing Address State Name:

WI

Provider Business Mailing Address Postal Code:

54619

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

608-654-5100

Provider Business Mailing Address Fax Number:

608-654-5120

Provider First Line Business Practice Location Address:

238 FRONT STREET

Provider Second Line Business Practice Location Address:

SCENIC BLUFFS HEALTH CENTER

Provider Business Practice Location Address City Name:

CASHTON

Provider Business Practice Location Address State Name:

WI

Provider Business Practice Location Address Postal Code:

54619

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

608-654-5100

Provider Business Practice Location Address Fax Number:

608-654-5120

Provider Enumeration Date:

09/21/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 1223G0001X , with the licence number:  07543 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 1223G0001X , with the licence number: 6171-015 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1003913 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
• Identifier: 07543 . This is a "IA STATE LICENSE #" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
• Identifier: 7543 . This is a "DELTA DENTAL (IA)" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
• Identifier: 0080200 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1417959 . This is a "CONTROLLED SUBSTANCE#" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
• Identifier: 421060724 . This is a "BILLING TAX ID# FOR CHC" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
• Identifier: 990360 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
• Identifier: IA0156 . This is a "JOHN DEERE EDI#" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
• Identifier: 1558357020 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 7543 . This is a "BC/BS OF IA-BLUE DENTAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".