=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144397415
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN LEE HORTON JR. D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 96 OLD MILL RD
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-9284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-0707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 96 OLD MILL RD
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-9284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-0707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2050
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------