1265636112 NPI number — LONNIE W. TINER, DDS, APC

Table of content: (NPI 1265636112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265636112 NPI number — LONNIE W. TINER, DDS, APC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONNIE W. TINER, DDS, APC
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:
1265636112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
56669 29 PALMS HWY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
YUCCA VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92284-5219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-365-0658
Provider Business Mailing Address Fax Number:
760-365-5308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
56669 29 PALMS HWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-5219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-365-0658
Provider Business Practice Location Address Fax Number:
760-365-5308
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TINER
Authorized Official First Name:
LONNIE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
760-365-0658

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G9196501 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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