Provider Demographics
NPI:1265757744
Name:SOUTH SIDE ORTHODONTICS
Entity type:Organization
Organization Name:SOUTH SIDE ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARKUS
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEPRASCHK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:434-977-9473
Mailing Address - Street 1:32 MILL CREEK DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-8718
Mailing Address - Country:US
Mailing Address - Phone:434-977-9473
Mailing Address - Fax:434-977-9417
Practice Address - Street 1:32 MILL CREEK DR
Practice Address - Street 2:SUITE 107
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-8718
Practice Address - Country:US
Practice Address - Phone:434-977-9473
Practice Address - Fax:434-977-9417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty