1023396058 NPI number — KID'S CHOICE DENTAL, INC

Table of content: MASAKO NISHIO MD (NPI 1356359855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023396058 NPI number — KID'S CHOICE DENTAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KID'S CHOICE DENTAL, INC
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:
FAMILY CHOICE DENTAL
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:
1023396058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 98TH ST NW STE C3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87121-9021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-352-5439
Provider Business Mailing Address Fax Number:
505-836-7533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 98TH ST NW STE C3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87121-9021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-352-5439
Provider Business Practice Location Address Fax Number:
505-821-8041
Provider Enumeration Date:
07/25/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NOYES
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
505-352-5439

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DD2523 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51004844 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1768244 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".