=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215126875
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUINCY DENTAL SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2007
-----------------------------------------------------
Last Update Date | 10/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 HAMPSHIRE
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-228-0536
-----------------------------------------------------
Fax | 217-223-1997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 HAMPSHIRE
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-228-0536
-----------------------------------------------------
Fax | 217-223-1997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TERENCE MAH
-----------------------------------------------------
Credential | DDS MS
-----------------------------------------------------
Telephone | 217-228-0536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------