1760987614 NPI number — REDLANDS ENDODONTICS

Table of content: (NPI 1760987614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760987614 NPI number — REDLANDS ENDODONTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REDLANDS ENDODONTICS
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:
1760987614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 TERRACINA BLVD STE 207B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92373-4869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-798-2228
Provider Business Mailing Address Fax Number:
909-798-2224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 TERRACINA BLVD SUITE 207 B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDLANDS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-798-2228
Provider Business Practice Location Address Fax Number:
909-798-2224
Provider Enumeration Date:
03/23/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SILVERS
Authorized Official First Name:
JENELLE
Authorized Official Middle Name:
MEREDITH
Authorized Official Title or Position:
ENDODONTIST
Authorized Official Telephone Number:
717-514-8227

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  59904 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1053613968 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".