1780745190 NPI number — FELLER AND FELLER ORTHODONTICS, LLC

Table of content: (NPI 1780745190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780745190 NPI number — FELLER AND FELLER ORTHODONTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FELLER AND FELLER ORTHODONTICS, 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:
FELLER AND FELLER 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:
1780745190
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2405 CASCADE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK SPRINGS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82901-5652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-362-8842
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2405 CASCADE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK SPRINGS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82901-5652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-362-8842
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FELLER
Authorized Official First Name:
PARLEY
Authorized Official Middle Name:
JACK
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
307-362-8842

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  743 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0400X , with the licence number: 1158 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 10578 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 743 . This is a "DELTA DENTAL" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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