1528067188 NPI number — JESSICA H BRIGATI D.D.S.

Table of content: JESSICA H BRIGATI D.D.S. (NPI 1528067188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528067188 NPI number — JESSICA H BRIGATI D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRIGATI
Provider First Name:
JESSICA
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
F

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:
1528067188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4900 OVERTON RIDGE BLVD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76132-1940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-370-0065
Provider Business Mailing Address Fax Number:
817-370-2699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4900 OVERTON RIDGE BLVD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76132-1940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-370-0065
Provider Business Practice Location Address Fax Number:
817-370-2699
Provider Enumeration Date:
07/17/2005

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: 1223G0001X , with the licence number:  20889 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D20889 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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