1952560278 NPI number — ADVANTAGE DENTAL CENTER

Table of content: (NPI 1952560278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952560278 NPI number — ADVANTAGE DENTAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE DENTAL CENTER
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:
1952560278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 W OVERLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-3051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-884-0888
Provider Business Mailing Address Fax Number:
208-895-8533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 W OVERLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-3051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-884-0888
Provider Business Practice Location Address Fax Number:
208-895-8533
Provider Enumeration Date:
06/02/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RICHINS
Authorized Official First Name:
LESTER
Authorized Official Middle Name:
ALBERT
Authorized Official Title or Position:
DOCTOR/OWNER
Authorized Official Telephone Number:
208-884-0888

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D3186 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001606900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6F126 . This is a "OTHER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".