1114127537 NPI number — DAVID R. TEBBENKAMP DDS PC

Table of content: (NPI 1114127537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114127537 NPI number — DAVID R. TEBBENKAMP DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID R. TEBBENKAMP DDS PC
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:
1114127537
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21788 AZEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAMASCUS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24236-4236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-388-3511
Provider Business Mailing Address Fax Number:
276-388-3163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21788 AZEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAMASCUS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24236-4236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-388-3511
Provider Business Practice Location Address Fax Number:
276-388-3163
Provider Enumeration Date:
07/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TEBBENKAMP
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
DENTIST/PRESIDENT
Authorized Official Telephone Number:
276-388-3511

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  0401004941 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 228633 . This is a "ANTHEM-BLUE CROSS BLUE SH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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