1972124717 NPI number — JEFFERSONVILLE COMMONS DENTAL

Table of content: SUZETTA DAWN DANIEL OTR (NPI 1609959485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972124717 NPI number — JEFFERSONVILLE COMMONS DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSONVILLE COMMONS DENTAL
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:
1972124717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1410 SPRING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSONVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47130-3731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-718-1226
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1019 JEFFERSONVILLE COMMONS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSONVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-302-3200
Provider Business Practice Location Address Fax Number:
812-302-3222
Provider Enumeration Date:
05/04/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FAETH
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
502-718-1226

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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