=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033371695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGETOWER DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2008
-----------------------------------------------------
Last Update Date | 06/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3250 N TOWERBRIDGE WAY
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-8347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-898-9355
-----------------------------------------------------
Fax | 208-898-9363
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3250 N TOWERBRIDGE WAY
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-8347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-898-9355
-----------------------------------------------------
Fax | 208-898-9363
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. THOMAS URGEL COX
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 208-898-9355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D3195
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------