Healthcare Provider Details

I. General information

NPI: 1689985509
Provider Name (Legal Business Name): ANDREK J INGERSOLL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1852 DESERT PEACH DR
CARSON CITY NV
89703-8321
US

IV. Provider business mailing address

2204 GLENWOOD AVE
PAPILLION NE
68046-5768
US

V. Phone/Fax

Practice location:
  • Phone: 919-656-3004
  • Fax:
Mailing address:
  • Phone: 402-972-8374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5653994-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number105496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: