1760852487 NPI number — CHANHASSEN SMILES DENTISTRY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760852487 NPI number — CHANHASSEN SMILES DENTISTRY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANHASSEN SMILES DENTISTRY, 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:
CHANHASSEN SMILES 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:
1760852487
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17000 RED HILL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92614-5626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-845-8890
Provider Business Mailing Address Fax Number:
949-474-1495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 LAKE DRIVE E
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
CHANHASSEN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-303-1737
Provider Business Practice Location Address Fax Number:
952-937-2761
Provider Enumeration Date:
10/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GEBHART
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
952-303-1737

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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