1700847043 NPI number — T.A. RAINBOLT, DDS, P.A.

Table of content: (NPI 1700847043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700847043 NPI number — T.A. RAINBOLT, DDS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T.A. RAINBOLT, DDS, P.A.
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:
OTTAWA KANSAS FAMILY DENTISTRY
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:
1700847043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1425 WAKARUSA DRIVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LAWRENCE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-841-3311
Provider Business Mailing Address Fax Number:
785-843-0421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1334 S. MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-242-5753
Provider Business Practice Location Address Fax Number:
785-242-8359
Provider Enumeration Date:
03/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAINBOLT
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
785-841-3311

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)





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