1679620520 NPI number — CARROLL DENTAL CLINIC P.L.C.

Table of content: (NPI 1679620520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679620520 NPI number — CARROLL DENTAL CLINIC P.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARROLL DENTAL CLINIC P.L.C.
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:
1679620520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
703 SIMON AVE
Provider Second Line Business Mailing Address:
PO BOX 997
Provider Business Mailing Address City Name:
CARROLL
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51401-2264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-792-4375
Provider Business Mailing Address Fax Number:
712-792-3371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 SIMON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARROLL
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51401-2264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-792-4375
Provider Business Practice Location Address Fax Number:
712-792-3371
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOGUE P.C.
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
712-792-4375

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 © 2007-2025 www.npivalidator.com