1265535652 NPI number — BRIDGEPORT DENTAL ARTS

Table of content: (NPI 1265535652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265535652 NPI number — BRIDGEPORT DENTAL ARTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGEPORT DENTAL ARTS
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:
1265535652
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4103 BRIDGEPORT WAY W
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
UNIVERSITY PLACE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-565-4474
Provider Business Mailing Address Fax Number:
253-565-6848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4103 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-565-4474
Provider Business Practice Location Address Fax Number:
253-565-6848
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHAW
Authorized Official First Name:
GARY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DENTIST OWNER
Authorized Official Telephone Number:
253-565-4474

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DE00006436 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 1431549922 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 601484620 . This is a "WASTEMPLOYMENT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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