1861572950 NPI number — MICHAEL W FUQUA DDS

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 1861572950 NPI number — MICHAEL W FUQUA DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL W FUQUA DDS
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:
ADVANCED DENTAL ASSOCIATES
Provider Other Organization Name Type Code:
5
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:
1861572950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
713 S TEXAS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESLACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-969-2960
Provider Business Mailing Address Fax Number:
956-969-3241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
713 S TEXAS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESLACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-969-2960
Provider Business Practice Location Address Fax Number:
956-969-3241
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FUQUA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
956-425-7474

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 16265 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 120848004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16265-02 . This is a "TEXAS CHIPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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