1437690104 NPI number — WOJTYNA DENTAL LLC

Table of content: MRS. BRIANNA DIANA DOSHNA ACSW (NPI 1548736986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437690104 NPI number — WOJTYNA DENTAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOJTYNA DENTAL LLC
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:
1437690104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3024 SR-159
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN CARBON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-205-6119
Provider Business Mailing Address Fax Number:
618-659-1343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6600 WEIGHLOCK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-454-6000
Provider Business Practice Location Address Fax Number:
866-803-4943
Provider Enumeration Date:
03/15/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KRAUSHAAR
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER RELATIONS
Authorized Official Telephone Number:
315-454-6000

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019027575 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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