1639486285 NPI number — FRIENDLY DENTAL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639486285 NPI number — FRIENDLY DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRIENDLY DENTAL
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:
1639486285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 3RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIBLEY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51249-1626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-754-2288
Provider Business Mailing Address Fax Number:
712-754-4865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIBLEY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51249-1626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-754-2288
Provider Business Practice Location Address Fax Number:
712-754-4865
Provider Enumeration Date:
09/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JARI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
507-376-5525

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  07092 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1922167410 . This is a "INDIVIDUAL NPI KELLY PHILLIPS, DDS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1316975568 . This is a "INDIVIDUAL NPI JERRY L. JOHNSON, DDS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1770672958 . This is a "PRIMARY LOCATION NPI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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