=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225161144
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM ETTINGER D.D.S, P.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 04/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3384 TAMIAMI TRL E
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34112-4931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-774-3017
-----------------------------------------------------
Fax | 239-774-5771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4680 CARDINAL WAY STE 201
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34112-6675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-774-3017
-----------------------------------------------------
Fax | 239-774-5771
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8153
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------