1912036013 NPI number — DR. ELLEN FAYE CAMPOMANES ALPANO DDS

Table of content: DR. ELLEN FAYE CAMPOMANES ALPANO DDS (NPI 1912036013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912036013 NPI number — DR. ELLEN FAYE CAMPOMANES ALPANO DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALPANO
Provider First Name:
ELLEN FAYE
Provider Middle Name:
CAMPOMANES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

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:
1912036013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POLACCA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86042-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-737-6162
Provider Business Mailing Address Fax Number:
928-737-6168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HIGHWAY 264 MILEPOST 388
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POLACCA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-737-6167
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  13745 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 955031 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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