Provider Demographics
NPI:1215204839
Name:NEIBAUER DENTAL CARE, PC
Entity Type:Organization
Organization Name:NEIBAUER DENTAL CARE, PC
Other - Org Name:FAMILY DENTAL CARE OF WARRENTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:251 WEST LEE HWY.
Mailing Address - Street 2:SUITE 197
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2047
Mailing Address - Country:US
Mailing Address - Phone:540-347-9364
Mailing Address - Fax:540-341-0183
Practice Address - Street 1:251 WEST LEE HWY.
Practice Address - Street 2:SUITE 197
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2047
Practice Address - Country:US
Practice Address - Phone:540-347-9364
Practice Address - Fax:540-341-0183
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:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414394122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty