1437334380 NPI number — BRIDGE CITY DENTISTRY P.C.

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 1437334380 NPI number — BRIDGE CITY DENTISTRY P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGE CITY DENTISTRY P.C.
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:
DENTAL ASSOCIATES OF VALLEY CITY P.C.
Provider Other Organization Name Type Code:
4
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:
1437334380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 CENTRAL AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEY CITY
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58072-3325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-845-4221
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
239 2ND AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLEY CITY
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58072-2909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-845-4221
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BERG
Authorized Official First Name:
CARON
Authorized Official Middle Name:
LYN
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
701-845-4221

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  1996 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1053510982 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1073681953 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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