1912218264 NPI number — WEST MILHAM DENTAL PROFESSIONALS PLLC

Table of content: (NPI 1912218264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912218264 NPI number — WEST MILHAM DENTAL PROFESSIONALS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST MILHAM DENTAL PROFESSIONALS PLLC
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:
1912218264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1416 W MILHAM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49024-2245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-381-0564
Provider Business Mailing Address Fax Number:
269-381-4965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1416 W MILHAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024-2245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-381-0564
Provider Business Practice Location Address Fax Number:
269-381-4965
Provider Enumeration Date:
07/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MOTSON
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-381-0564

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  2901019482 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com