1265983985 NPI number — IB DENTAL III

Table of content: (NPI 1265983985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265983985 NPI number — IB DENTAL III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IB DENTAL III
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:
IBRUSH FAMILY DENTAL CARE
Provider Other Organization Name Type Code:
3
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:
1265983985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2970 BELCREST CENTER DR
Provider Second Line Business Mailing Address:
STE. 105
Provider Business Mailing Address City Name:
HYATTSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20782-1912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-567-5437
Provider Business Mailing Address Fax Number:
301-567-5456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2970 BELCREST CENTER DR
Provider Second Line Business Practice Location Address:
STE. 105
Provider Business Practice Location Address City Name:
HYATTSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20782-1987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-567-5437
Provider Business Practice Location Address Fax Number:
301-567-5456
Provider Enumeration Date:
10/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DAYSE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
SHEROD
Authorized Official Title or Position:
CEO AND PRESIDENT
Authorized Official Telephone Number:
202-297-1500

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  15968 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 14139 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 126800000X , with the licence number: 02372 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 126800000X , with the licence number: 18788 , 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)





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