=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043238959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETTY R OSTROW DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10502 PARK ROAD SSUITE 100
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-544-3363
-----------------------------------------------------
Fax | 704-544-3133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10502 PARK ROAD SSUITE 100
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-544-3363
-----------------------------------------------------
Fax | 704-544-3133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BETTY R OSTROW
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 704-544-3363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | NC6524
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------