1184663718 NPI number — DR. JED RYAN NORMAN DDS

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 1184663718 NPI number — DR. JED RYAN NORMAN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORMAN
Provider First Name:
JED
Provider Middle Name:
RYAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1184663718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1813 W HARVARD STE 221
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-672-6511
Provider Business Mailing Address Fax Number:
541-673-1892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1813 W HARVARD STE 221
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-672-6511
Provider Business Practice Location Address Fax Number:
541-673-1892
Provider Enumeration Date:
06/06/2006

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:  D3831 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: D8859 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 806926400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 278647 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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