1528424702 NPI number — PARKLANE DENTAL PA

Table of content: (NPI 1528424702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528424702 NPI number — PARKLANE DENTAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKLANE DENTAL PA
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:
ADVENTURE DENTAL AND VISION
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:
1528424702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2221 E BIJOU ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80909-8009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-955-8896
Provider Business Mailing Address Fax Number:
719-955-3470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
980 S OLIVER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
97218-3216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-221-3008
Provider Business Practice Location Address Fax Number:
316-221-3015
Provider Enumeration Date:
01/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
URBANOZO
Authorized Official First Name:
SHAUN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
719-323-2362

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  61154 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 61154 . This is a "KANSAS DENTAL BOARD LICENSE NUMBER" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com