1689762494 NPI number — KIMBERLY PARK DENTAL ASSOCIATES

Table of content: (NPI 1689762494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689762494 NPI number — KIMBERLY PARK DENTAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBERLY PARK DENTAL ASSOCIATES
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:
MARC C SLIVKEN DAVID A JOHNSON THOMAS A THOL
Provider Other Organization Name Type Code:
5
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:
1689762494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3512 JERSEY RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52807-3332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3512 JERSEY RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52807-3332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-359-3494
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THUL
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT DENTIST
Authorized Official Telephone Number:
563-359-3494

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)

  • Identifier: 710728 . This is a "BLUE CROSS S" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 755644 . This is a "BLUE CROSS J" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 709842 . This is a "BLUE CROSS T" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0099382 . This is a "SLIVKEN" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0096222 . This is a "JOHNSON" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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