1699137109 NPI number — COUNTRY CLUB DENTAL PA

Table of content: (NPI 1699137109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699137109 NPI number — COUNTRY CLUB DENTAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY CLUB DENTAL PA
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:
1699137109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2221 E BIJOU ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80909-8009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-576-1850
Provider Business Mailing Address Fax Number:
719-955-3470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 SW 29TH ST
Provider Second Line Business Practice Location Address:
SUITE M
Provider Business Practice Location Address City Name:
TOPEKA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66611-1164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-783-5981
Provider Business Practice Location Address Fax Number:
785-783-5982
Provider Enumeration Date:
03/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
URBANOZO
Authorized Official First Name:
SHAUN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
719-323-2362

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201199030A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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