1376698738 NPI number — SOUTHWEST FAMILY DENTISTRY, LLC

Table of content: (NPI 1376698738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376698738 NPI number — SOUTHWEST FAMILY DENTISTRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST FAMILY DENTISTRY, LLC
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:
1376698738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6724 PERIMETER LOOP RD # 312
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43017-3202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-276-1661
Provider Business Mailing Address Fax Number:
614-276-1664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
699 HARRISBURG PIKE
Provider Second Line Business Practice Location Address:
SUITE N-P
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43223-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-276-1661
Provider Business Practice Location Address Fax Number:
614-276-1664
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ENGLAND
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRINCIPAL MEMBER
Authorized Official Telephone Number:
614-276-1661

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  30018576 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0701413 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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