1093787624 NPI number — MECKLER DENTAL PROVIDERS (OLMSTED), INC

Table of content: GABRIELLE IDALIA BUNNEY MD (NPI 1790289981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093787624 NPI number — MECKLER DENTAL PROVIDERS (OLMSTED), INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MECKLER DENTAL PROVIDERS (OLMSTED), 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:
Provider Other Organization Name Type Code:
6
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:
1093787624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 860036
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55486-0036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-734-6500
Provider Business Mailing Address Fax Number:
216-584-1004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4710 GREAT NORTHERN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH OLMSTED
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44070-3427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-716-6939
Provider Business Practice Location Address Fax Number:
216-584-1004
Provider Enumeration Date:
02/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STAUTIHAR
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISOR, CREDENTIALING
Authorized Official Telephone Number:
216-584-1673

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223E0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 30.017994 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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