1659619609 NPI number — EAGLE SMILES DENTISTRY AND ORTHODONTICS, PC

Table of content: (NPI 1659619609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659619609 NPI number — EAGLE SMILES DENTISTRY AND ORTHODONTICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE SMILES DENTISTRY AND ORTHODONTICS, PC
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:
6
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:
1659619609
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2860 MICHELLE FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92606-1008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-368-2077
Provider Business Mailing Address Fax Number:
714-508-6400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6700 N LINDER RD STE 132
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-6608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-895-8555
Provider Business Practice Location Address Fax Number:
208-895-8556
Provider Enumeration Date:
01/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HOWARD
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER DOCTOR
Authorized Official Telephone Number:
208-895-8555

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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