1093933749 NPI number — GAUDENZIA INC

Table of content: DR. BRADFORD JAY RHODES DMD (NPI 1407853567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093933749 NPI number — GAUDENZIA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GAUDENZIA 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:
1093933749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 WEST MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORRISTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19401-4716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-239-9600
Provider Business Mailing Address Fax Number:
610-275-7025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
91 BROAD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-875-2287
Provider Business Practice Location Address Fax Number:
570-875-2203
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
SR. CONTRACT MANAGER
Authorized Official Telephone Number:
484-338-3731

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  547023 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1002285890066 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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