1114385473 NPI number — SHIPLEY DENTAL INNOVATIONS LLC

Table of content: (NPI 1477561983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114385473 NPI number — SHIPLEY DENTAL INNOVATIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIPLEY DENTAL INNOVATIONS LLC
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:
SHIPLEY DENTAL INNOVATIONS
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:
1114385473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1904 E CENTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARSAW
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46580-3701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-376-4244
Provider Business Mailing Address Fax Number:
574-306-2711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1904 E CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARSAW
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46580-3701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-376-4244
Provider Business Practice Location Address Fax Number:
574-306-2711
Provider Enumeration Date:
02/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SHIPLEY
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
574-377-6426

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  12009310 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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