1558446310 NPI number — AGAWAM DENTAL CARE PC

Table of content: (NPI 1558446310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558446310 NPI number — AGAWAM DENTAL CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAWAM DENTAL CARE PC
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:
1558446310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1182 SPRINGFIELD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FEEDING HILLS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01030-2115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-786-7313
Provider Business Mailing Address Fax Number:
413-786-7542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1182 SPRINGFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEEDING HILLS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01030-2115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-786-7313
Provider Business Practice Location Address Fax Number:
413-786-7542
Provider Enumeration Date:
10/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PAHL
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
413-786-7313

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  18025 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0277819 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".