1104249259 NPI number — CAMPODONICO FAMILY & COSMETIC DENTISTRY PC

Table of content: (NPI 1104249259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104249259 NPI number — CAMPODONICO FAMILY & COSMETIC DENTISTRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMPODONICO FAMILY & COSMETIC DENTISTRY PC
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:
6
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:
1104249259
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11806 ABERDEEN ST NE
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
BLAINE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55449-4736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-786-1545
Provider Business Mailing Address Fax Number:
763-786-2939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11806 ABERDEEN ST NE
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
BLAINE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55449-4736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-786-1545
Provider Business Practice Location Address Fax Number:
763-786-2939
Provider Enumeration Date:
01/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CAMPODONICO
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
ERNESTO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-786-1545

Provider Taxonomy Codes

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

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

  • Identifier: 1154546877 . This is a "NPI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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