1518137652 NPI number — ELLIE HEYDARI DDS

Table of content: ELLIE HEYDARI DDS (NPI 1518137652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518137652 NPI number — ELLIE HEYDARI DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEYDARI
Provider First Name:
ELLIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

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:
1518137652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36745 AIKEN RD
Provider Second Line Business Mailing Address:
36745 AIKEN RD.
Provider Business Mailing Address City Name:
BAYFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54814-4579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-779-3707
Provider Business Mailing Address Fax Number:
715-779-3622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36745 AIKEN RD.
Provider Second Line Business Practice Location Address:
RED CLIFF COMMUNITY HEALTH CENTER
Provider Business Practice Location Address City Name:
BAYFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-779-3707
Provider Business Practice Location Address Fax Number:
715-779-3622
Provider Enumeration Date:
03/05/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2901017468 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 7252-15 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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