=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205326162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARSON FAMILY DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2018
-----------------------------------------------------
Last Update Date | 05/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24300 CHAGRIN BLVD
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-464-0442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8505 TANGLEWOOD SQ STE T17
-----------------------------------------------------
City | CHAGRIN FALLS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44023-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-543-1234
-----------------------------------------------------
Fax | 440-543-1205
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. R CHRISTOPHER CARSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 440-543-1234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 20891
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------