1689754327 NPI number — NOONAN, BROCKMAN AND POLLOCK, D.D.S., INC.

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 1689754327 NPI number — NOONAN, BROCKMAN AND POLLOCK, D.D.S., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOONAN, BROCKMAN AND POLLOCK, D.D.S., INC.
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:
NOONAN AND BROCKMAN, D.D.S., INC.
Provider Other Organization Name Type Code:
4
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:
1689754327
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 S BREIEL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45044-5157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-423-9239
Provider Business Mailing Address Fax Number:
513-423-4188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 S BREIEL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45044-5157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-423-9239
Provider Business Practice Location Address Fax Number:
513-423-4188
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CORWIN
Authorized Official First Name:
AIMEE
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNTS MANAGER
Authorized Official Telephone Number:
513-423-9239

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  13948 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0743637 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2705826 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0184072 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0701379 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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