1841395829 NPI number — DR. CORDELL W TOLLIVER DMD

Table of content: DR. CORDELL W TOLLIVER DMD (NPI 1841395829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841395829 NPI number — DR. CORDELL W TOLLIVER DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOLLIVER
Provider First Name:
CORDELL
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TOLLIVER
Provider Other First Name:
CORDELL
Provider Other Middle Name:
W
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1841395829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 EXETER AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLESBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40965-1461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-248-5302
Provider Business Mailing Address Fax Number:
606-248-5302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 EXETER AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLESBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40965-1461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-248-5302
Provider Business Practice Location Address Fax Number:
606-248-5302
Provider Enumeration Date:
09/14/2006

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: 122300000X , with the licence number:  4989 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0160739 . This is a "BCBS TENN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0688009 . This is a "DELTA DENTAL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 60049897 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".