1972018174 NPI number — CARSON V BROWN II DDS LLC

Table of content: (NPI 1972018174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972018174 NPI number — CARSON V BROWN II DDS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARSON V BROWN II DDS LLC
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:
1972018174
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MC ELHATTAN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17748-0450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-769-9130
Provider Business Mailing Address Fax Number:
570-769-9133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 MCELHATTAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCELHATTAN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17748-0450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-769-9130
Provider Business Practice Location Address Fax Number:
570-769-9133
Provider Enumeration Date:
12/11/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
CARSON
Authorized Official Middle Name:
VICTOR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-769-9130

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DS-026291-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 18-54448914 . This is a "NPI ENTITY 1" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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