1023408192 NPI number — SPECIAL NEEDS DENTISTRY

Table of content: (NPI 1023408192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023408192 NPI number — SPECIAL NEEDS DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIAL NEEDS 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:
1023408192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16304 COUNTY ROAD 2040
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79423-4618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-368-2005
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2420 QUAKER AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79410-1817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-701-5066
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
REDDELL
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
806-701-5066

Provider Taxonomy Codes

  • Taxonomy code: 1223D0001X , with the licence number:  19405 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180035102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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