1326025974 NPI number — CHILDREN'S MEDICAID DENTAL CLINIC, PC

Table of content: (NPI 1326025974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326025974 NPI number — CHILDREN'S MEDICAID DENTAL CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S MEDICAID DENTAL CLINIC, PC
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:
1326025974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 W 8TH ST
Provider Second Line Business Mailing Address:
SUITE 810
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81003-3038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-562-4447
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5115 W THOMAS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85031-3944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-233-3133
Provider Business Practice Location Address Fax Number:
602-278-3139
Provider Enumeration Date:
12/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
TRUDY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, LICENSING & CREDENTIALING
Authorized Official Telephone Number:
615-750-0342

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 619661 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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