1245537604 NPI number — DR. CANDICE NICOLE GHAZZOULI DMD

Table of content: DR. CANDICE NICOLE GHAZZOULI DMD (NPI 1245537604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245537604 NPI number — DR. CANDICE NICOLE GHAZZOULI DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHAZZOULI
Provider First Name:
CANDICE
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARPENTER
Provider Other First Name:
CANDICE
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245537604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1660 SYCAMORE RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MONTOURSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17754-9314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-323-4819
Provider Business Mailing Address Fax Number:
570-323-7057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1660 SYCAMORE RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MONTOURSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17754-9314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-323-4819
Provider Business Practice Location Address Fax Number:
570-323-7057
Provider Enumeration Date:
02/22/2011

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:  DS037471 , 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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