=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205125226
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE COMPREHENSIVE DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2011
-----------------------------------------------------
Last Update Date | 03/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4720 AIRPORT BLVD
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36608-3134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-344-4994
-----------------------------------------------------
Fax | 251-345-8872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4720 AIRPORT BLVD
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36608-3134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-344-4994
-----------------------------------------------------
Fax | 251-345-8872
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF
-----------------------------------------------------
Name | MS. CHRISTIE VAUGHN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 251-344-4994
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5206
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5486
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3001
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------