Provider Demographics
NPI:1285901801
Name:NEIBAUER DENTAL CARE, P.C.
Entity type:Organization
Organization Name:NEIBAUER DENTAL CARE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8330
Mailing Address - Street 1:6141 HIGHBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715
Mailing Address - Country:US
Mailing Address - Phone:301-801-6404
Mailing Address - Fax:301-262-8609
Practice Address - Street 1:6141 HIGHBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715
Practice Address - Country:US
Practice Address - Phone:301-801-6404
Practice Address - Fax:301-262-8609
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEIBAUER DENTAL CARE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-28
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
MD158711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty