1285664961 NPI number — TEGWYN BRICKHOUSE DDS

Table of content: TEGWYN BRICKHOUSE DDS (NPI 1285664961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285664961 NPI number — TEGWYN BRICKHOUSE DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRICKHOUSE
Provider First Name:
TEGWYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

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:
1285664961
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
521 N 11TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23298-5045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-828-9095
Provider Business Mailing Address Fax Number:
804-827-1244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
521 N 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23298-5045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-828-9095
Provider Business Practice Location Address Fax Number:
804-827-1244
Provider Enumeration Date:
07/05/2006

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: 1223P0221X , with the licence number:  0411000034 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01-0025621 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0018308 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 463655 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".