Provider Demographics
NPI:1245340355
Name:AMY EVERETT DDS AND ASSOCIATES PLLC
Entity type:Organization
Organization Name:AMY EVERETT DDS AND ASSOCIATES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:PAULINE
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-599-1234
Mailing Address - Street 1:503 BURROUGHS ST STE 105
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3386
Mailing Address - Country:US
Mailing Address - Phone:304-599-1234
Mailing Address - Fax:304-599-5105
Practice Address - Street 1:503 BURROUGHS ST STE 105
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3386
Practice Address - Country:US
Practice Address - Phone:304-599-1234
Practice Address - Fax:304-599-5105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3095OtherLICENSE
WV001376012OtherUNITED CONCORDIA IND
WV001810168OtherUNITED CONCORDIA GROUP
WV4001075000Medicaid
WV3810004441Medicaid
WV000636495OtherUNITED CONCORDIA IND
WV0133692001Medicaid
WVCS1529500111OtherCARESOURCE IND
WV169320540798OtherHUMANA
WV3530OtherLICENSE
WVCS1529400264OtherCARESOURCE IND