1982262283 NPI number — DR. ZACHARY TYLER FERGUSON DMD

Table of content: DR. ZACHARY TYLER FERGUSON DMD (NPI 1982262283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982262283 NPI number — DR. ZACHARY TYLER FERGUSON DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
ZACHARY
Provider Middle Name:
TYLER
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:
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:
1982262283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 4TH ST APT 14
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61920-2851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-953-2859
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
522 E JASPER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61944-2437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-466-3090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2019

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:  019.032071 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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