1740391648 NPI number — MRS. MICHELLE NANESE RUIZ DDS

Table of content: MRS. MICHELLE NANESE RUIZ DDS (NPI 1740391648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740391648 NPI number — MRS. MICHELLE NANESE RUIZ DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUIZ
Provider First Name:
MICHELLE
Provider Middle Name:
NANESE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

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:
1740391648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2017 WESTWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79124-1330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-373-5751
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 S COULTER ST
Provider Second Line Business Practice Location Address:
BLDG G, SUITE 500
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79106-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-351-2762
Provider Business Practice Location Address Fax Number:
806-351-2763
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  17910 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1571853 01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: G60131 01 . This is a "CHIPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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