1679013569 NPI number — DR. RICHARD A SHORT DMD, DR. RONNI ANN SCHNELL DMD

Table of content: (NPI 1679013569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679013569 NPI number — DR. RICHARD A SHORT DMD, DR. RONNI ANN SCHNELL DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. RICHARD A SHORT DMD, DR. RONNI ANN SCHNELL DMD
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:
THE CLASSIC SMILE
Provider Other Organization Name Type Code:
3
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:
1679013569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92 HIGH ST
Provider Second Line Business Mailing Address:
SUITE DH 11-12
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02155-3850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-396-4131
Provider Business Mailing Address Fax Number:
781-396-2064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
92 HIGH ST
Provider Second Line Business Practice Location Address:
SUITE DH 11-12
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-3850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-396-4131
Provider Business Practice Location Address Fax Number:
781-396-2064
Provider Enumeration Date:
02/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SHORT
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PROVIDER/OWNER
Authorized Official Telephone Number:
781-396-4131

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com