Provider Demographics
NPI:1326315037
Name:NEIBAUER DENTAL CARE, PC
Entity Type:Organization
Organization Name:NEIBAUER DENTAL CARE, PC
Other - Org Name:NEIBAUER DENTAL CARE - HERNDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:12973 HIGHLAND CROSSING DR STE E
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-5890
Mailing Address - Country:US
Mailing Address - Phone:703-435-9178
Mailing Address - Fax:703-435-9839
Practice Address - Street 1:12973 HIGHLAND CROSSING DR STE E
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-5890
Practice Address - Country:US
Practice Address - Phone:703-435-9178
Practice Address - Fax:703-435-9839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEIBAUER DENTAL CARE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty