1740694181 NPI number — WAFELBAKKER ANDERSON ORTHODONTICS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740694181 NPI number — WAFELBAKKER ANDERSON ORTHODONTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAFELBAKKER ANDERSON ORTHODONTICS
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:
1740694181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1855 SAN MIGUEL DR
Provider Second Line Business Mailing Address:
STE 33
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94596-5279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-935-5630
Provider Business Mailing Address Fax Number:
925-934-8130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1855 SAN MIGUEL DR
Provider Second Line Business Practice Location Address:
STE 33
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94596-5279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-935-5630
Provider Business Practice Location Address Fax Number:
925-934-8130
Provider Enumeration Date:
06/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WAFELBAKKER
Authorized Official First Name:
BAS
Authorized Official Middle Name:
WILLEM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
925-935-5630

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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