=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205966835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN F.D. CHIKES D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 W FULTON ST
-----------------------------------------------------
City | EPHRATA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17522-1937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-738-4901
-----------------------------------------------------
Fax | 717-738-1259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 480 SNYDER RD
-----------------------------------------------------
City | LITITZ
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17543-7683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-626-2890
-----------------------------------------------------
Fax | 717-738-1259
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DS-025555L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------