1891960688 NPI number — DENTISTRY FOR KIDS P.A.

Table of content: (NPI 1891960688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891960688 NPI number — DENTISTRY FOR KIDS P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTISTRY FOR KIDS P.A.
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:
1891960688
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1014 ERIKSON DR. #A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REXBURG
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-238-1567
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1014 ERIKSON DR #A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-1567
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MCWHORTER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
208-237-1567

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  D-3451-PD , 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: 805759500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9200611 . This is a "IDAHO SMILES PROVIDER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com