1073920864 NPI number — COULON DENTAL CARE

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 1073920864 NPI number — COULON DENTAL CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COULON DENTAL CARE
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:
1073920864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 N GARFIELD ST
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79705-6400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-683-5313
Provider Business Mailing Address Fax Number:
432-683-8195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 N GARFIELD ST
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79705-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-683-5313
Provider Business Practice Location Address Fax Number:
432-683-8195
Provider Enumeration Date:
07/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WILKE
Authorized Official First Name:
JENNY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
432-683-5313

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  30078 , 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)





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