1376576207 NPI number — DR. KENNETH ALEXANDER POOLE II DMD

Table of content: MARINA MARY SEELY-RICKER (NPI 1477055754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376576207 NPI number — DR. KENNETH ALEXANDER POOLE II DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POOLE
Provider First Name:
KENNETH
Provider Middle Name:
ALEXANDER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
Provider Credential Text:
DMD
Provider Gender Code:
M

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:
1376576207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4020 DUPLIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27407-7763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-315-0943
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2835 HORSE PEN CREEK RD STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27410-9700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-662-0807
Provider Business Practice Location Address Fax Number:
336-662-0828
Provider Enumeration Date:
07/07/2006

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: 1223G0001X , with the licence number:  6081 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8996986 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 810-41 . This is a "BCBS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 864646 . This is a "PENN. BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 40706 . This is a "BCBS OF TENN." identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 96986 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: V0068 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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