=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205055704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS RANDALL PARHAM D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1702 RIDGEWOOD AVE
-----------------------------------------------------
City | HOLLY HILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32117-5416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-672-1830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3947 TANO DR
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-9306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-676-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN0012537
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------