1174771802 NPI number — DR. SIOBHIAN MELINDA BACCHUS SPROTT DDS, MPA

Table of content: DR. SIOBHIAN MELINDA BACCHUS SPROTT DDS, MPA (NPI 1174771802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174771802 NPI number — DR. SIOBHIAN MELINDA BACCHUS SPROTT DDS, MPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPROTT
Provider First Name:
SIOBHIAN
Provider Middle Name:
MELINDA BACCHUS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS, MPA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BACCHUS
Provider Other First Name:
SIOBHIAN
Provider Other Middle Name:
MELINDA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS, MPA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174771802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2221 E BIJOU ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80909-8009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-576-1850
Provider Business Mailing Address Fax Number:
719-955-3470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 GEORGIA AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-829-5437
Provider Business Practice Location Address Fax Number:
202-829-9255
Provider Enumeration Date:
09/06/2008

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: 1223P0221X , with the licence number:  DN1857887 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: 0401412318 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: DEN1000855 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 15112 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 037892500 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".