Provider Demographics
NPI:1295002814
Name:NEIBAUER DENTAL CARE, PC
Entity Type:Organization
Organization Name:NEIBAUER DENTAL CARE, PC
Other - Org Name:NEIBAUER DENTAL CARE - MANASSAS
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 1:10051 MARKET CIR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-2120
Mailing Address - Country:US
Mailing Address - Phone:571-921-9103
Mailing Address - Fax:703-335-5161
Practice Address - Street 1:10051 MARKET CIR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-2120
Practice Address - Country:US
Practice Address - Phone:571-921-9103
Practice Address - Fax:703-335-5161
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