1487794798 NPI number — ON SITE DENTAL, PC

Table of content: (NPI 1487794798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487794798 NPI number — ON SITE DENTAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ON SITE DENTAL, 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:
6
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:
1487794798
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 767
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMP VERDE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86322-0767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-567-1832
Provider Business Mailing Address Fax Number:
928-567-6500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1996 DOUGS PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMP VERDE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-567-1832
Provider Business Practice Location Address Fax Number:
928-567-6500
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HISRICH
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
928-567-1832

Provider Taxonomy Codes

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

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

  • Identifier: G2381 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 723157 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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