1801964739 NPI number — DAVID M DETTMAN D.D.S.

Table of content: DAVID M DETTMAN D.D.S. (NPI 1801964739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801964739 NPI number — DAVID M DETTMAN D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETTMAN
Provider First Name:
DAVID
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

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:
1801964739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 N 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEBRASKA CITY
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68410-2329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-873-5040
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 ILLINOIS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIDNEY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-374-2029
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2006

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:  6865 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 5136 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0091421 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470681388001 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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