=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144613365
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE MACRAE HIGGINBOTTOM D.D.S. M.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2015
-----------------------------------------------------
Last Update Date | 05/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 556 CYNWOOD DR STE A
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21601-3886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-822-3626
-----------------------------------------------------
Fax | 410-822-9520
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 556 CYNWOOD DR STE A
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21601-3886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-822-3626
-----------------------------------------------------
Fax | 410-822-9520
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 15388
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------