=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023285202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COSMETIC AND FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2008
-----------------------------------------------------
Last Update Date | 05/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2008 N US HIGHWAY 71
-----------------------------------------------------
City | CARROLL
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51401-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-792-6455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2008 N US HIGHWAY 71
-----------------------------------------------------
City | CARROLL
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51401-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-792-6455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ELIZABETH EVANS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 712-792-6455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 7806
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------