1245340355 NPI number — AMY EVERETT DDS AND ASSOCIATES PLLC

Table of content: (NPI 1245340355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245340355 NPI number — AMY EVERETT DDS AND ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMY EVERETT DDS AND ASSOCIATES PLLC
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:
1245340355
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
503 BURROUGHS ST STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26505-3386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-599-1234
Provider Business Mailing Address Fax Number:
304-599-5105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 BURROUGHS ST STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-3386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-599-1234
Provider Business Practice Location Address Fax Number:
304-599-5105
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVERETT
Authorized Official First Name:
AMY
Authorized Official Middle Name:
PAULINE
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
304-599-1234

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3095 . This is a "LICENSE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001376012 . This is a "UNITED CONCORDIA IND" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001810168 . This is a "UNITED CONCORDIA GROUP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 4001075000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810004441 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000636495 . This is a "UNITED CONCORDIA IND" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0133692001 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS1529500111 . This is a "CARESOURCE IND" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 169320540798 . This is a "HUMANA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3530 . This is a "LICENSE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: CS1529400264 . This is a "CARESOURCE IND" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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