1104091388 NPI number — FLEETWOOD DENTAL PROFESSIONAL CORPORATION

Table of content: DR. KARL WASHINGTON ISAACS M.D. (NPI 1568491710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104091388 NPI number — FLEETWOOD DENTAL PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLEETWOOD DENTAL PROFESSIONAL CORPORATION
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:
1104091388
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 N RICHMOND STREET
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
FLEETWOOD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-944-9771
Provider Business Mailing Address Fax Number:
610-944-0702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 N RICHMOND STREET
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FLEETWOOD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-944-9771
Provider Business Practice Location Address Fax Number:
610-944-0702
Provider Enumeration Date:
04/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
610-944-9771

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DS036286 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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