1730161175 NPI number — KENNETH B WEDDELL DDS PC

Table of content: (NPI 1730161175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730161175 NPI number — KENNETH B WEDDELL DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH B WEDDELL DDS PC
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:
FREMONT DENTAL ASSOCIATES PC
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:
1730161175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 437
Provider Second Line Business Mailing Address:
111 W DAYTON ST
Provider Business Mailing Address City Name:
FREMONT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49412-0437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-924-3600
Provider Business Mailing Address Fax Number:
231-924-9720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 W DAYTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49412-1112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-924-3600
Provider Business Practice Location Address Fax Number:
231-924-9720
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WEDDELL
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
B
Authorized Official Title or Position:
REPRESENTATIVE
Authorized Official Telephone Number:
231-924-3600

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 847376 . This is a "UN CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: D808140 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com