1962850933 NPI number — AVALON DENTAL PC

Table of content: (NPI 1962850933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962850933 NPI number — AVALON DENTAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVALON DENTAL 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:
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:
1962850933
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
672 E WYTHE CREEK CT
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
KUNA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83634-5216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-629-2800
Provider Business Mailing Address Fax Number:
208-629-2801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
672 E WYTHE CREEK CT
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
KUNA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83634-5216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-629-2800
Provider Business Practice Location Address Fax Number:
208-629-2801
Provider Enumeration Date:
05/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GRANT
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-629-2800

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  D3875 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1447345491 . This is a "INDIVIDUAL PROVIDER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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