1609922863 NPI number — DR. JERRY JOSEPH LEBEDA JR. DDS

Table of content: DR. JERRY JOSEPH LEBEDA JR. DDS (NPI 1609922863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609922863 NPI number — DR. JERRY JOSEPH LEBEDA JR. DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEBEDA
Provider First Name:
JERRY
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
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:
1609922863
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:
19 HERITAGE DR
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
BOURBONNAIS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60914-1369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-933-3479
Provider Business Mailing Address Fax Number:
815-933-8698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 HERITAGE DR
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
BOURBONNAIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60914-1369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-933-3479
Provider Business Practice Location Address Fax Number:
815-933-8698
Provider Enumeration Date:
01/28/2007

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 , 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)





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