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1235790510 NPI number — BACKCOUNTRY DENTAL DOCS, LLC

NPI Number: 1235790510
Health Care Provider/Practitioner: BACKCOUNTRY DENTAL DOCS, LLC

Information about “1235790510” NPI (BACKCOUNTRY DENTAL DOCS, LLC) exists in 1235790510 in HTML format HTML  |  1235790510 in plain Text format TXT  |  1235790510 in PDF (Portable Document Format) PDF  |  1235790510 in an XML format XML  formats.

NPI Number : 1235790510 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1235790510",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "BACKCOUNTRY DENTAL DOCS, LLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "2691 E THOMAS HILL DR",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "COEUR D ALENE",
    "MailingAddressStateName": "ID",
    "MailingAddressPostalCode": "83815-6335",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "425-409-1655",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "109 MCKINLEY AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "KELLOGG",
    "PracticeLocationAddressStateName": "ID",
    "PracticeLocationAddressPostalCode": "83837-2501",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "208-784-0545",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "06/26/2019",
    "LastUpdateDate": "10/03/2022",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "BERRY",
    "AuthorizedOfficialFirstName": "HILLARY",
    "AuthorizedOfficialMiddleName": "ANNE",
    "AuthorizedOfficialTitle": "MANAGER",
    "AuthorizedOfficialNamePrefix": "DR.",
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "DMD",
    "AuthorizedOfficialTelephoneNumber": "425-409-1655",
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "261QD0000X",
          "TaxonomyName": "Dental Clinic/Center",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "122300000X",
          "TaxonomyName": "Dentist",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY  GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
      }
    }
  }
}
                
            

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