=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013190149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATIVE SMILES FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2007
-----------------------------------------------------
Last Update Date | 12/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 608 S TRENTON ST
-----------------------------------------------------
City | RUTHERFORD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38369-9715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-665-7240
-----------------------------------------------------
Fax | 731-665-7268
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 38 608 S. TRENTON ST
-----------------------------------------------------
City | RUTHERFORD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38369-0038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-665-7240
-----------------------------------------------------
Fax | 731-665-7268
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/ OWNER
-----------------------------------------------------
Name | DR. WARREN FRED STOVALL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 731-665-7240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 7612
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------