=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174945596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID J PURDY DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2014
-----------------------------------------------------
Last Update Date | 01/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 W PARK AVE
-----------------------------------------------------
City | HEREFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79045-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-364-4496
-----------------------------------------------------
Fax | 806-364-4981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 809 W PARK AVE
-----------------------------------------------------
City | HEREFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79045-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-364-4496
-----------------------------------------------------
Fax | 806-364-4981
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/OWNER
-----------------------------------------------------
Name | DR. DAVID J PURDY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 806-364-4496
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 13674
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------