1679129316 NPI number — MRS. JILLIAN RENEE CALDWELL D.M.D.

Table of content: MRS. JILLIAN RENEE CALDWELL D.M.D. (NPI 1679129316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679129316 NPI number — MRS. JILLIAN RENEE CALDWELL D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALDWELL
Provider First Name:
JILLIAN
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KERSTEN
Provider Other First Name:
JILLIAN
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679129316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20713 E. OCOTILLO RD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
QUEEN CREEK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-888-8123
Provider Business Mailing Address Fax Number:
480-888-8374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20713 E. OCOTILLO RD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
QUEEN CREEK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-888-8123
Provider Business Practice Location Address Fax Number:
480-888-8374
Provider Enumeration Date:
08/16/2019

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:  10461 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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