1356514772 NPI number — ALEXANDER DENTAL GROUOP CHTD.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356514772 NPI number — ALEXANDER DENTAL GROUOP CHTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALEXANDER DENTAL GROUOP CHTD.
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:
1356514772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 HANSEN ST E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWIN FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83301-6254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-733-7566
Provider Business Mailing Address Fax Number:
208-734-4267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 HANSEN ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-6254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-733-7566
Provider Business Practice Location Address Fax Number:
208-734-4267
Provider Enumeration Date:
04/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SHARP
Authorized Official First Name:
JEANETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
208-733-7566

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 181859 . This is a "IDAHO SMILES" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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