1558076653 NPI number — GLOW UP DENTISTRY, PLLC

Table of content: (NPI 1558076653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558076653 NPI number — GLOW UP DENTISTRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLOW UP DENTISTRY, PLLC
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:
1558076653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10310 W GRAND PKWY S STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77406-5924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
346-843-8743
Provider Business Mailing Address Fax Number:
346-843-8757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10310 W GRAND PKWY S STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77406-5924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
346-843-8743
Provider Business Practice Location Address Fax Number:
346-843-8757
Provider Enumeration Date:
01/23/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
UNEGBU
Authorized Official First Name:
GINGER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
346-843-8743

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1881251353 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".