1164622395 NPI number — WALTER R. PFITZINGER D.D.S,, P.C.

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 1164622395 NPI number — WALTER R. PFITZINGER D.D.S,, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALTER R. PFITZINGER D.D.S,, P.C.
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:
MID MISSOURI DENTAL CENTER
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:
1164622395
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 VANDIVER DR
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65202-3932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-814-1694
Provider Business Mailing Address Fax Number:
573-814-2845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 VANDIVER DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65202-3932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-814-1694
Provider Business Practice Location Address Fax Number:
573-814-2845
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
KERRI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
573-814-1694

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  010435 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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