=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114364239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEATH DENTAL PARTNERS, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2013
-----------------------------------------------------
Last Update Date | 05/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 HEBRON RD
-----------------------------------------------------
City | HEATH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43056-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-788-8084
-----------------------------------------------------
Fax | 740-788-8094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 613 HEBRON RD
-----------------------------------------------------
City | HEATH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43056-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-788-8084
-----------------------------------------------------
Fax | 740-788-8094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNERS
-----------------------------------------------------
Name | BRANDON S CANFIELD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 740-788-8084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30023922
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------