1952419855 NPI number — ABOUT YOUR SMILE PC

Table of content: (NPI 1952419855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952419855 NPI number — ABOUT YOUR SMILE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABOUT YOUR SMILE 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:
Provider Other Organization Name Type Code:
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:
1952419855
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6776 MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPPER DARBY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-734-0015
Provider Business Mailing Address Fax Number:
610-734-1419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6776 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER DARBY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-734-0015
Provider Business Practice Location Address Fax Number:
610-734-1419
Provider Enumeration Date:
08/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-734-0115

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: 401786 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0009098000001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".