1013943612 NPI number — JOE W ABDELNOUR DDS MS

Table of content: JOE W ABDELNOUR DDS MS (NPI 1013943612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013943612 NPI number — JOE W ABDELNOUR DDS MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABDELNOUR
Provider First Name:
JOE
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS MS
Provider Gender Code:
M

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:
1013943612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1467 PALMA RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
BULLHEAD CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-763-1203
Provider Business Mailing Address Fax Number:
928-758-1072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1467 PALMA ROAD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
BULLHEAD CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-763-1203
Provider Business Practice Location Address Fax Number:
928-758-1072
Provider Enumeration Date:
06/24/2006

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: 1223S0112X , with the licence number:  D4537 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34223B . This is a "AAHCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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