1487189528 NPI number — WASHBURN FAMILY DENTAL CARE, INC

Table of content: (NPI 1487189528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487189528 NPI number — WASHBURN FAMILY DENTAL CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASHBURN FAMILY DENTAL CARE, INC
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:
MOORES MILL DENTAL CARE
Provider Other Organization Name Type Code:
3
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:
1487189528
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2164 MOORES MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36830-8447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-750-5720
Provider Business Mailing Address Fax Number:
334-209-0515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2164 MOORES MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36830-8447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-750-5720
Provider Business Practice Location Address Fax Number:
334-209-0515
Provider Enumeration Date:
04/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WASHBURN
Authorized Official First Name:
ERNEST
Authorized Official Middle Name:
JASON
Authorized Official Title or Position:
DOCTOR/OWNER
Authorized Official Telephone Number:
334-750-5720

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5247 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 5120 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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