Basic Information
Provider Information | |||||||||
NPI: | 1326331588 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NE HEIGHTS MODERN DENTISTRY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NE HEIGHTS MODERN DENTISTRY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17000 RED HILL AVE | ||||||||
Address2: |   | ||||||||
City: | IRVINE | ||||||||
State: | CA | ||||||||
PostalCode: | 926145626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148458890 | ||||||||
FaxNumber: | 9494741495 | ||||||||
Practice Location | |||||||||
Address1: | 5901 WYOMING BLVD NE STE W | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871093859 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5058214422 | ||||||||
FaxNumber: | 5057978280 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2011 | ||||||||
LastUpdateDate: | 08/05/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCANN | ||||||||
AuthorizedOfficialFirstName: | KATIE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER DR | ||||||||
AuthorizedOfficialTelephone: | 5058214422 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.