=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215155387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THEODORE R. POPE DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 W WENGER RD
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45322-2724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-832-2087
-----------------------------------------------------
Fax | 937-836-7901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 W WENGER RD
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45322-2724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-832-2087
-----------------------------------------------------
Fax | 937-836-7901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THEODORE R POPE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 937-832-2087
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 30014318
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------