1013074095 NPI number — WESTNEDGE FAMILY DENTISTRY

Table of content: (NPI 1013074095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013074095 NPI number — WESTNEDGE FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTNEDGE FAMILY DENTISTRY
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:
1013074095
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:
3907 S WESTNEDGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49008-3187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-345-8893
Provider Business Mailing Address Fax Number:
269-492-1710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3907 S WESTNEDGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49008-3187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-345-8893
Provider Business Practice Location Address Fax Number:
269-492-1710
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SACKETT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
269-345-8893

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  14741 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 16115 . This is a "MI DELTA DENTAL # JUNGBLU" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3273360 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17761 . This is a "MASON-DELTA DENTAL MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2901016115 . This is a "TIM JUNGBLUT STATE LICENS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2901017761 . This is a "LICENSE #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2901014741 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 14741 . This is a "SACKETT-DELTA DENTAL #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3273324 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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