Provider Demographics
NPI:1023385648
Name:NEIBAUER DENTAL CARE, PC
Entity Type:Organization
Organization Name:NEIBAUER DENTAL CARE, PC
Other - Org Name:NEIBAUER DENTAL CARE - WOODBRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORD.
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:14901 POTOMAC TOWN PL
Mailing Address - Street 2:SUITE 175
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4096
Mailing Address - Country:US
Mailing Address - Phone:703-580-5515
Mailing Address - Fax:703-583-1487
Practice Address - Street 1:14901 POTOMAC TOWN PL
Practice Address - Street 2:SUITE 175
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4096
Practice Address - Country:US
Practice Address - Phone:703-580-5515
Practice Address - Fax:703-583-1487
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEIBAUER DENTAL CARE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty