1316302599 NPI number — BILTMORE PEDIATRIC DENTAL GROUP

Table of content: (NPI 1316302599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316302599 NPI number — BILTMORE PEDIATRIC DENTAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BILTMORE PEDIATRIC DENTAL GROUP
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:
MYKIDZDENTIST CENTRAL PHOENIX
Provider Other Organization Name Type Code:
3
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:
1316302599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1728 W GLENDALE AVE
Provider Second Line Business Mailing Address:
#305
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85021-8860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-995-7336
Provider Business Mailing Address Fax Number:
602-995-2665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1728 W GLENDALE AVE
Provider Second Line Business Practice Location Address:
#305
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85021-8860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-995-7336
Provider Business Practice Location Address Fax Number:
602-995-2665
Provider Enumeration Date:
12/15/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NEHRER
Authorized Official First Name:
ERNEST
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
831-234-5526

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  8935 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 955781 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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