Healthcare Provider Details

I. General information

NPI: 1215204839
Provider Name (Legal Business Name): NEIBAUER DENTAL CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 WEST LEE HWY. SUITE 197
WARRENTON VA
20186-2047
US

IV. Provider business mailing address

251 WEST LEE HWY. SUITE 197
WARRENTON VA
20186-2047
US

V. Phone/Fax

Practice location:
  • Phone: 540-347-9364
  • Fax: 540-341-0183
Mailing address:
  • Phone: 540-347-9364
  • Fax: 540-341-0183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401414394
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KENDRA WALKER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-8312