1487635926 NPI number — AESTHETIC DENTISTRY PC

Table of content: (NPI 1487635926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487635926 NPI number — AESTHETIC DENTISTRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AESTHETIC DENTISTRY PC
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:
ERIC A DZIURDZIEL DDS & MARY KAY KRIVY DDS PC
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:
1487635926
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:
2029 BLUEGRASS CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEYENNE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82009-7368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-632-6597
Provider Business Mailing Address Fax Number:
307-632-2170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2029 BLUEGRASS CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82009-7368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-632-6597
Provider Business Practice Location Address Fax Number:
307-632-2170
Provider Enumeration Date:
11/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KRIVY
Authorized Official First Name:
MARY
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
DDS DENTIST
Authorized Official Telephone Number:
307-632-6597

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  WY963 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: WY967 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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