1164560165 NPI number — EAST TOWNE DENTAL ASSOCIATES BELGIUM FAMILY DENTAL SC

Table of content: MRS. CAROLINE BANTA DEROSA APRN (NPI 1841685831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164560165 NPI number — EAST TOWNE DENTAL ASSOCIATES BELGIUM FAMILY DENTAL SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TOWNE DENTAL ASSOCIATES BELGIUM FAMILY DENTAL SC
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:
1164560165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELGIUM
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-285-3408
Provider Business Mailing Address Fax Number:
262-285-4025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
171 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BELGIUM
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-285-3408
Provider Business Practice Location Address Fax Number:
262-285-4025
Provider Enumeration Date:
02/02/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KIAIE
Authorized Official First Name:
VALI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
262-285-3408

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5301 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 5993 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 5304 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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