1750450052 NPI number — COSMOPOLITAN DENTISTRY

Table of content: (NPI 1750450052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750450052 NPI number — COSMOPOLITAN DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COSMOPOLITAN DENTISTRY
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:
1750450052
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:
225 ABERDEEN DR
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
VALPARAISO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46385-7762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-548-2322
Provider Business Mailing Address Fax Number:
312-577-0841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 ABERDEEN DR
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46385-7762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-548-2322
Provider Business Practice Location Address Fax Number:
312-577-0841
Provider Enumeration Date:
11/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CUELLAR
Authorized Official First Name:
LUIS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-548-2322

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  12008232A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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