1629483466 NPI number — JEBEDIAH S CHRISTY, D.D.S. - VIENNA, PLLC

Table of content: (NPI 1629483466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629483466 NPI number — JEBEDIAH S CHRISTY, D.D.S. - VIENNA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEBEDIAH S CHRISTY, D.D.S. - VIENNA, PLLC
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:
1629483466
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13220-3189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-273-8204
Provider Business Mailing Address Fax Number:
866-803-4943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 GRAND CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIENNA
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26105-2140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-273-8204
Provider Business Practice Location Address Fax Number:
866-803-4943
Provider Enumeration Date:
06/30/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BERTOLLINI
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRS
Authorized Official Telephone Number:
866-273-8204

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  4081 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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