1699833210 NPI number — ANDREW E FORMAN ORTHODONTICS LLC

Table of content: (NPI 1699833210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699833210 NPI number — ANDREW E FORMAN ORTHODONTICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDREW E FORMAN ORTHODONTICS LLC
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:
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:
1699833210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7119 E SHEA BLVD
Provider Second Line Business Mailing Address:
SUITE # 109-312
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85254-6107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-843-1000
Provider Business Mailing Address Fax Number:
480-443-7165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20100 N 51ST AVE
Provider Second Line Business Practice Location Address:
SUITE B230
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-5125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-843-1000
Provider Business Practice Location Address Fax Number:
480-443-7165
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FORMAN
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
602-843-1000

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  1625 , registered in the state of AZ ; 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