Provider Demographics
NPI:1629345251
Name:NEIBAUER DENTAL CARE, PC
Entity Type:Organization
Organization Name:NEIBAUER DENTAL CARE, PC
Other - Org Name:WALDORF ORTHODONTICS
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:217-540-5100
Mailing Address - Street 1:10665 STANHAVEN PL STE 105
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-3056
Mailing Address - Country:US
Mailing Address - Phone:301-632-5480
Mailing Address - Fax:301-632-6083
Practice Address - Street 1:10665 STANHAVEN PL STE 105
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3056
Practice Address - Country:US
Practice Address - Phone:301-632-5480
Practice Address - Fax:301-632-6083
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:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty