=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225376882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRHOPE DENTISTRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2013
-----------------------------------------------------
Last Update Date | 01/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10939 US HIGHWAY 98
-----------------------------------------------------
City | FAIRHOPE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36532-5408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-928-9930
-----------------------------------------------------
Fax | 251-928-9956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10939 US HIGHWAY 98
-----------------------------------------------------
City | FAIRHOPE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36532-5408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-928-9930
-----------------------------------------------------
Fax | 251-928-9956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT DENTIST
-----------------------------------------------------
Name | DR. SLAVOLJUB DJURIC
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 251-928-9930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5894
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------