1477667913 NPI number — CHILDREN'S DENTAL CLINIC, PC

Table of content: (NPI 1477667913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477667913 NPI number — CHILDREN'S DENTAL CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S DENTAL CLINIC, 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:
1477667913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2840 S 70TH ST
Provider Second Line Business Mailing Address:
SUITE 7-352
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68506-3662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-384-0332
Provider Business Mailing Address Fax Number:
402-797-2064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3721 W 13TH
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-384-0332
Provider Business Practice Location Address Fax Number:
402-797-2064
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MEYER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
PHILIP
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
308-384-0332

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  4908 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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