1891005468 NPI number — HERITAGE CREEK DENTAL OF ALBIA LLC

Table of content: (NPI 1891005468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891005468 NPI number — HERITAGE CREEK DENTAL OF ALBIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE CREEK DENTAL OF ALBIA LLC
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:
HERITAGE CREEK DENTAL
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:
1891005468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBIA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52531-2041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBIA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52531-2041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-932-2729
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TIMMERMAN
Authorized Official First Name:
CLINTON
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
PRESIDENT/DENTIST
Authorized Official Telephone Number:
641-932-2729

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  08515 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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