1336552678 NPI number — WILLIAMSBURG DENTAL HEALTH CLINIC INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336552678 NPI number — WILLIAMSBURG DENTAL HEALTH CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAMSBURG DENTAL HEALTH CLINIC INC
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:
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:
1336552678
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 296
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSBURG
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52361-0296
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-668-9808
Provider Business Mailing Address Fax Number:
319-668-9735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
827 S HIGHLAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52361-9333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-668-9808
Provider Business Practice Location Address Fax Number:
319-668-9735
Provider Enumeration Date:
06/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GRIER
Authorized Official First Name:
BENTON
Authorized Official Middle Name:
PHILLIP
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
319-470-9140

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)





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