1003966102 NPI number — NORTHWOOD FAMILY DENTISTRY, INC.

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 1003966102 NPI number — NORTHWOOD FAMILY DENTISTRY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWOOD FAMILY DENTISTRY, INC.
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:
1003966102
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:
1001 N MAIN ST
Provider Second Line Business Mailing Address:
SUITE TWO
Provider Business Mailing Address City Name:
NAPPANEE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46550-1016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-773-7979
Provider Business Mailing Address Fax Number:
574-773-7292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE TWO
Provider Business Practice Location Address City Name:
NAPPANEE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46550-1016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-773-7979
Provider Business Practice Location Address Fax Number:
574-773-7292
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BAUMGARTNER
Authorized Official First Name:
JOE
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
574-773-7979

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12007757B , 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)





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