1396814182 NPI number — PARRA FAMILY DENTISTRY PC

Table of content: (NPI 1396814182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396814182 NPI number — PARRA FAMILY DENTISTRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARRA FAMILY DENTISTRY 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:
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:
1396814182
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/08/2013
NPI Reactivation Date:
09/04/2013

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 L STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-731-5423
Provider Business Mailing Address Fax Number:
402-884-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 L STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-731-5423
Provider Business Practice Location Address Fax Number:
402-884-5955
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EDMONDS
Authorized Official First Name:
JODENE
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTAL MANAGER
Authorized Official Telephone Number:
402-731-5423

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025130200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025602000 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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