1194786863 NPI number — DR. ERIC COONTZ DDS DENTISTRY

Table of content: DR. ERIC COONTZ DDS DENTISTRY (NPI 1194786863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194786863 NPI number — DR. ERIC COONTZ DDS DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COONTZ
Provider First Name:
ERIC
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS DENTISTRY
Provider Gender Code:
M

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:
1194786863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 467
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZUNI
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87327-0467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-782-4431
Provider Business Mailing Address Fax Number:
505-782-7327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
US DHHS INDIAN HEALTH SERVICE
Provider Second Line Business Practice Location Address:
ROUTE 301 NORTH B STREET
Provider Business Practice Location Address City Name:
ZUNI
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87327-0467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-782-4431
Provider Business Practice Location Address Fax Number:
505-782-7327
Provider Enumeration Date:
03/31/2006

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: 122300000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 62802 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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