1912157371 NPI number — CRYSTAL LEE BILL DMD

Table of content: CRYSTAL LEE BILL DMD (NPI 1912157371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912157371 NPI number — CRYSTAL LEE BILL DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BILL
Provider First Name:
CRYSTAL
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BORHAM
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912157371
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
706 E BELL RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85022-6641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-482-7000
Provider Business Mailing Address Fax Number:
602-482-7021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6849 N ORACLE RD STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85704-4242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-696-0700
Provider Business Practice Location Address Fax Number:
520-696-0705
Provider Enumeration Date:
09/23/2008

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: 1223G0001X , with the licence number:  7657 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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