1740741073 NPI number — BRACES PLUS PC

Table of content: KAITLYN CLARK (NPI 1508359241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740741073 NPI number — BRACES PLUS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRACES PLUS PC
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:
6
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:
1740741073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1916 NINTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST THOMAS
Provider Business Mailing Address State Name:
VI
Provider Business Mailing Address Postal Code:
00802-2640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
340-776-0030
Provider Business Mailing Address Fax Number:
340-774-9760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1916 NINTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST THOMAS
Provider Business Practice Location Address State Name:
VI
Provider Business Practice Location Address Postal Code:
00802-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
340-776-0030
Provider Business Practice Location Address Fax Number:
340-774-9760
Provider Enumeration Date:
03/28/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CONNOR
Authorized Official First Name:
TREVOR
Authorized Official Middle Name:
A. C
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
340-776-0030

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1477742237 , issued by the state of ( VI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com