1861695926 NPI number — HENRY E RABUN JR. DMD

Table of content: HENRY E RABUN JR. DMD (NPI 1861695926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861695926 NPI number — HENRY E RABUN JR. DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RABUN
Provider First Name:
HENRY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RABUN
Provider Other First Name:
HANK
Provider Other Middle Name:
ELWYNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1861695926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2926 PROFESSIONAL PARKWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-860-0575
Provider Business Mailing Address Fax Number:
706-860-4186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2926 PROFESSIONAL PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-860-0575
Provider Business Practice Location Address Fax Number:
706-860-4186
Provider Enumeration Date:
06/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  10238 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003246628 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".