1780606616 NPI number — BEARABLE DENTISTRY

Table of content: (NPI 1780606616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780606616 NPI number — BEARABLE DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEARABLE DENTISTRY
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:
1780606616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1410 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOSCOW
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83843-8930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-882-3214
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-8930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-882-3214
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF INSURANCE COORDINATION
Authorized Official Telephone Number:
208-882-3214

Provider Taxonomy Codes

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

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

  • Identifier: CS9246 . This is a "CONTROLLED SUBSTANCE NUMB" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: D-3556 . This is a "DENTAL" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: D-3565 . This is a "DENTAL" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: CS2043 . This is a "CONTROLLED SUBSTANCE #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: CS9172 . This is a "CONTROLLED SUBSTANCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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