=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154675312
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC SHAWN MCMASTER IPDH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2012
-----------------------------------------------------
Last Update Date | 11/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 343 WATER ST
-----------------------------------------------------
City | GARDINER
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04345-2160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-620-4763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 343 WATER ST
-----------------------------------------------------
City | GARDINER
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04345-2160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | IPDH54
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------