1063661163 NPI number — DR. THOMAS H. CARTLEDGE III D.D.S., M.S.

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 1063661163 NPI number — DR. THOMAS H. CARTLEDGE III D.D.S., M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARTLEDGE
Provider First Name:
THOMAS
Provider Middle Name:
H.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
D.D.S., M.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DESANTIS
Provider Other First Name:
BRIANNE
Provider Other Middle Name:
C.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.M.D., M.S.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1063661163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 N OLD KINGS RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-9505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
138-672-4981
Provider Business Mailing Address Fax Number:
386-673-1476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 N OLD KINGS RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174-9505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
138-672-4981
Provider Business Practice Location Address Fax Number:
386-673-1476
Provider Enumeration Date:
09/12/2008

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: 1223X0400X , with the licence number:  DN0004071 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0740527 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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