=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174939599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARESS DENTAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2014
-----------------------------------------------------
Last Update Date | 07/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 N MAIN ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02904-5764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-272-1238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 N MAIN ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02904-5764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ELIZEU LIMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-272-1238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2531
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------