=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033579289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEARL COSMETIC DENTISTRY & AESTHETICS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2016
-----------------------------------------------------
Last Update Date | 03/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7215 SAWMILL RD STE 210
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43016-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-698-0325
-----------------------------------------------------
Fax | 614-698-0327
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7215 SAWMILL RD STE 210
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43016-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-698-0325
-----------------------------------------------------
Fax | 614-698-0327
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. WHITNEY M MOORE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 614-698-0325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------