1265442073 NPI number — DR. BRIAN ANDREW PRENTICE DDS

Table of content: (NPI 1629565189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265442073 NPI number — DR. BRIAN ANDREW PRENTICE DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRENTICE
Provider First Name:
BRIAN
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
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:
1265442073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14831 W 159TH ST STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOCKPORT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60491-9008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-324-5369
Provider Business Mailing Address Fax Number:
815-744-7059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14831 W 159TH ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCKPORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60491-9008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-324-5369
Provider Business Practice Location Address Fax Number:
815-744-7059
Provider Enumeration Date:
08/08/2006

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: 1223G0001X , with the licence number:  019.031399 , 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: 1295165439 . This is a "BARRINGTON SVC LOCATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: P01931253 . This is a "RAILROAD PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: F400420356 . This is a "MEDICARE PART B PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1760882005 . This is a "SKOKIE SVC LOCATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1205145554 . This is a "SHOREWOOD SVC LOCATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1306177241 . This is a "OAKBROOK SVC LOCATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1508198474 . This is a "CHICAGO SVC LOCATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: F400420355 . This is a "MEDICARE PART B PTAN" identifier . This identifiers is of the category "OTHER".




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