1225458763 NPI number — CLEARWHITE DENTAL PLLC

Table of content: (NPI 1225458763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225458763 NPI number — CLEARWHITE DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEARWHITE DENTAL PLLC
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:
1225458763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1831 NORTH BELCHER ROAD
Provider Second Line Business Mailing Address:
SUITE F-3
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33765-1453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-791-8823
Provider Business Mailing Address Fax Number:
727-725-4534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1831 N BELCHER RD
Provider Second Line Business Practice Location Address:
SUITE F-3
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33765-1449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-791-8823
Provider Business Practice Location Address Fax Number:
727-725-4534
Provider Enumeration Date:
04/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
JERGINS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
BRADLEY
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
727-791-8823

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  DN15034 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DN15034 . This is a "STATE DENTAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com