1891826335 NPI number — DEBRA K. OLDHAM DDS PC

Table of content: (NPI 1891826335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891826335 NPI number — DEBRA K. OLDHAM DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEBRA K. OLDHAM DDS PC
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:
ANAMOSA DENTAL ASSOC. PC
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:
1891826335
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANAMOSA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52205-1636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-462-2531
Provider Business Mailing Address Fax Number:
319-462-2914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANAMOSA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52205-1636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-462-2531
Provider Business Practice Location Address Fax Number:
319-462-2914
Provider Enumeration Date:
03/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OLDHAM
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
319-462-2531

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42053 . This is a "DELTA DENTAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".