1427193382 NPI number — DR. CARL LARUE KNOX DDS

Table of content: SUGUNA GOTTAM DDS (NPI 1932308673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427193382 NPI number — DR. CARL LARUE KNOX DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNOX
Provider First Name:
CARL
Provider Middle Name:
LARUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNOX
Provider Other First Name:
CARL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS PLLC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1427193382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14818 PACIFIC AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-531-0638
Provider Business Mailing Address Fax Number:
253-536-7928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14818 PACIFIC AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-531-0638
Provider Business Practice Location Address Fax Number:
253-536-7928
Provider Enumeration Date:
02/20/2007

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:  5943 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0143 . This is a "WASHINGTON DENTAL SERVICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 614482 . This is a "UNITED CONCORDIA INS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 129840361 . This is a "AMERICAN DENTAL ASSOCIATI" identifier . This identifiers is of the category "OTHER".
  • Identifier: KN707 . This is a "REGENCE BLUE CROSS BLUE S" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5092507 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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