1316935232 NPI number — NANCY LEE GOODARE-ROSENTHAL DDS, MS

Table of content: NANCY LEE GOODARE-ROSENTHAL DDS, MS (NPI 1316935232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316935232 NPI number — NANCY LEE GOODARE-ROSENTHAL DDS, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODARE-ROSENTHAL
Provider First Name:
NANCY
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS, MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOODARE
Provider Other First Name:
NANCY
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS,MS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316935232
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 N HARBOR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60601-7364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-588-3146
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 N HARBOR DR
Provider Second Line Business Practice Location Address:
APT 2409
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60601-5007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-996-7546
Provider Business Practice Location Address Fax Number:
312-355-4173
Provider Enumeration Date:
10/13/2005

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: 122300000X , with the licence number:  019.030532 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 8414 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 60501332 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 94984018 . This is a "NEW MEXICO MEDICAID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 840706945137 . This is a "ROCKY MOUNTAIN HEALTH PLA" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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