Provider Demographics
NPI:1316203433
Name:TOOTH FAIRY PC
Entity Type:Organization
Organization Name:TOOTH FAIRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:POORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-234-5437
Mailing Address - Street 1:121 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-3001
Mailing Address - Country:US
Mailing Address - Phone:308-234-5437
Mailing Address - Fax:308-234-3169
Practice Address - Street 1:121 E 31ST ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-3001
Practice Address - Country:US
Practice Address - Phone:308-234-5437
Practice Address - Fax:308-234-3169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE56461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty