1629356209 NPI number — OMNI DENTAL, LLC

Table of content: (NPI 1629356209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629356209 NPI number — OMNI DENTAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMNI 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:
1629356209
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7111 PROSPECT PL NE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87110-4309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-888-5131
Provider Business Mailing Address Fax Number:
505-888-5135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7111 PROSPECT PL NE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87110-4309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-888-5131
Provider Business Practice Location Address Fax Number:
505-888-5135
Provider Enumeration Date:
07/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CHANG
Authorized Official First Name:
PE
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
505-888-5131

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DD2344 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1505220 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 55120725 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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