1134430325 NPI number — JACK L. SEMMENS DDS DENTAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134430325 NPI number — JACK L. SEMMENS DDS DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACK L. SEMMENS DDS DENTAL CORPORATION
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:
1134430325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
495 NO LAKE BLVD, - P.O. BOX 1912
Provider Second Line Business Mailing Address:
SUITE 270
Provider Business Mailing Address City Name:
TAHOE CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-583-5546
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 NO LAKE BLVD
Provider Second Line Business Practice Location Address:
SUITE 270
Provider Business Practice Location Address City Name:
TAHOE CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-583-5546
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SEMMENS
Authorized Official First Name:
JACK
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
530-583-5546

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  18407 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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