1083765853 NPI number — SALLY POPE-BURNS DMD

Table of content: SALLY POPE-BURNS DMD (NPI 1083765853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083765853 NPI number — SALLY POPE-BURNS DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POPE-BURNS
Provider First Name:
SALLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

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:
1083765853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1907 OLD MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAYSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41056-8926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-759-5401
Provider Business Mailing Address Fax Number:
606-759-5783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1907 OLD MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAYSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41056-8926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-759-5401
Provider Business Practice Location Address Fax Number:
606-759-5783
Provider Enumeration Date:
01/16/2007

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: 1223G0001X , with the licence number:  6783 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 642325 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 60067832 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6194309800 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4500384500 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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