1801101191 NPI number — KIDS PEDIATRIC DENTISTRY, PA

Table of content: (NPI 1801101191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801101191 NPI number — KIDS PEDIATRIC DENTISTRY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDS PEDIATRIC DENTISTRY, PA
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:
1801101191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
335 N ALLEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75013-2539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-727-0011
Provider Business Mailing Address Fax Number:
972-727-0707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 N ALLEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75013-2539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-727-0011
Provider Business Practice Location Address Fax Number:
972-727-0707
Provider Enumeration Date:
08/11/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROWOLD-GARCIAMENDEZ
Authorized Official First Name:
ELISABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-727-0011

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  18425 , 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: 0912743-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900-53478 . This is a "BCBS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 0000ZBX696 . This is a "BCBS OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 85D713 . This is a "BCBS OF TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 861423 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".