1962574590 NPI number — DR. JUDY K PEDRO-LIM D.M.D., M.D.S.

Table of content: DR. JUDY K PEDRO-LIM D.M.D., M.D.S. (NPI 1962574590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962574590 NPI number — DR. JUDY K PEDRO-LIM D.M.D., M.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDRO-LIM
Provider First Name:
JUDY
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D., M.D.S.
Provider Gender Code:
F

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:
1962574590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4640 SLATER RD
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55122-4043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-808-5252
Provider Business Mailing Address Fax Number:
651-808-5253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4640 SLATER RD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-4043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-808-5252
Provider Business Practice Location Address Fax Number:
651-808-5253
Provider Enumeration Date:
11/15/2006

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: 1223P0221X , with the licence number:  D10662 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 485517500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".