1598040578 NPI number — JILL K. MIODUSKI, DDS, MS, PROFESSIONAL LLC

Table of content: (NPI 1598040578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598040578 NPI number — JILL K. MIODUSKI, DDS, MS, PROFESSIONAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JILL K. MIODUSKI, DDS, MS, PROFESSIONAL LLC
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:
NORTHERN COLORADO ORTHODONTICS
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:
1598040578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1295 MAIN ST
Provider Second Line Business Mailing Address:
#4
Provider Business Mailing Address City Name:
WINDSOR
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80550-5966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-674-0717
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1295 MAIN ST
Provider Second Line Business Practice Location Address:
#4
Provider Business Practice Location Address City Name:
WINDSOR
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80550-5966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-674-0717
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MIODUSKI
Authorized Official First Name:
JILL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER/ORTHODONTIST
Authorized Official Telephone Number:
970-674-0717

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  10178 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com