1477944742 NPI number — CORDICA DENTAL DESIGNS

Table of content: DR. CRYSTAL JING YU MD (NPI 1861052367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477944742 NPI number — CORDICA DENTAL DESIGNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORDICA DENTAL DESIGNS
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:
1477944742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 W BRANDON BLVD
Provider Second Line Business Mailing Address:
STE 106
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33511-5104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-661-1800
Provider Business Mailing Address Fax Number:
813-661-1300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 W BRANDON BLVD
Provider Second Line Business Practice Location Address:
STE 106
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-661-1800
Provider Business Practice Location Address Fax Number:
813-661-1300
Provider Enumeration Date:
02/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR, DMD/PRESIDENT
Authorized Official Telephone Number:
813-422-2599

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN15530 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 014265500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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