=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003976093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEDAR LANE FAMILY DENTISTRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 06/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 CEDAR LANE
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46131-1089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-736-7476
-----------------------------------------------------
Fax | 317-736-1946
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 850 CEDAR LANE
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46131-1089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-736-7476
-----------------------------------------------------
Fax | 317-736-1946
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST CEO
-----------------------------------------------------
Name | DR. PHILIP JAMES MIRISE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 317-736-7476
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12009980
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------