1245303387 NPI number — OMEGA ENDODONTICS, LLC

Table of content: (NPI 1245303387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245303387 NPI number — OMEGA ENDODONTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMEGA ENDODONTICS, LLC
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:
1245303387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 OMEGA DR
Provider Second Line Business Mailing Address:
SUITE J-31
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-2058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-733-7600
Provider Business Mailing Address Fax Number:
302-733-7522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 OMEGA DR
Provider Second Line Business Practice Location Address:
SUITE J-31
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-733-7600
Provider Business Practice Location Address Fax Number:
302-733-7522
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LIU
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
PARTNER ENDODONTIST
Authorized Official Telephone Number:
302-733-7600

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  2005207676 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1576242 . This is a "UNITED CONCORDIA PROVIDER" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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