1952741316 NPI number — DR. TRAE HARBESON PAPPAS D.D.S.

Table of content: DR. TRAE HARBESON PAPPAS D.D.S. (NPI 1952741316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952741316 NPI number — DR. TRAE HARBESON PAPPAS D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAPPAS
Provider First Name:
TRAE
Provider Middle Name:
HARBESON
Provider Name Prefix Text:
DR.
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:
1952741316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
287 BRIARWOOD CIR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32548-3901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-685-8461
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5170 S FERDON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32536-9258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-689-2332
Provider Business Practice Location Address Fax Number:
850-683-0524
Provider Enumeration Date:
07/01/2013

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:  DN 20233 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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