1750403911 NPI number — CHILDRENS ENDODONTIC SERVICES, PC

Table of content: (NPI 1750403911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750403911 NPI number — CHILDRENS ENDODONTIC SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDRENS ENDODONTIC SERVICES, PC
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:
1750403911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 WAKEFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PETERSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23805-2112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-733-6740
Provider Business Mailing Address Fax Number:
804-733-8687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 WAKEFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23805-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-733-6740
Provider Business Practice Location Address Fax Number:
804-733-8687
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NESBITT
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
EVETTE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
804-733-6740

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  0401412670 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3225803 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5360 . This is a "TENNESSEE DENTAL LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: DN19669 . This is a "FLORIDA LIMITED DENTAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0401412670 . This is a "VIRGINIA DENTAL LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: DEN1000852 . This is a "WASHINGTON DC DENTAL LICENSE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 004708800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1184607756 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45003936 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60003308 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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