=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427305580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAD BARRETT NOSEK D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2012
-----------------------------------------------------
Last Update Date | 05/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27949 GREENSPOT RD SUITE H
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92346-4443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-864-6010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1179 E PARIS AVE SE STE 130
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-3682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-618-3440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 61669
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223D0004X
-----------------------------------------------------
Taxonomy Name | Dental Anesthesiology
-----------------------------------------------------
License Number | 2901600916
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------