Provider Demographics
NPI:1396012936
Name:NEIBAUER DENTAL CARE, P.C.
Entity Type:Organization
Organization Name:NEIBAUER DENTAL CARE, P.C.
Other - Org Name:LIFETIME DENTISTRY AT SHORT PUMP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALL
Authorized Official - Middle Name:
Authorized Official - Last Name:CREDENTIALING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:12244 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1062
Mailing Address - Country:US
Mailing Address - Phone:804-360-8890
Mailing Address - Fax:804-360-8894
Practice Address - Street 1:12244 W BROAD ST
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1062
Practice Address - Country:US
Practice Address - Phone:804-360-8890
Practice Address - Fax:804-360-8894
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:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413582122300000X
VA0401412223122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty