1588699664 NPI number — MR. GEOFFREY R WARDA DDS

Table of content: MR. GEOFFREY R WARDA DDS (NPI 1588699664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588699664 NPI number — MR. GEOFFREY R WARDA DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARDA
Provider First Name:
GEOFFREY
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1588699664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5631 SANDHILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-821-0567
Provider Business Mailing Address Fax Number:
608-833-1737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7007 OLD SAUK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-833-2060
Provider Business Practice Location Address Fax Number:
608-833-1737
Provider Enumeration Date:
07/11/2006

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: 1223S0112X , with the licence number:  5079015 , 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)

  • Identifier: 33753400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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