1174702765 NPI number — MISS JEANINE RENE DENTAL HYGIENIST RDH

Table of content: MISS JEANINE RENE DENTAL HYGIENIST RDH (NPI 1174702765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174702765 NPI number — MISS JEANINE RENE DENTAL HYGIENIST RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RENE
Provider First Name:
JEANINE
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
DENTAL HYGIENIST RDH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RENE
Provider Other First Name:
JEANINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
DENTAL HYGIENIST
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1174702765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47 CONCORD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02186-1116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-449-8610
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 BLUE HILL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTAPAN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02126-2253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-296-0061
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  13617 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com