=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235440884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERIODONTAL HEALTH CENTER, PL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2010
-----------------------------------------------------
Last Update Date | 06/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5522 GULF DR
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-4022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-847-1239
-----------------------------------------------------
Fax | 727-845-4595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5522 GULF DR
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-4022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-847-1239
-----------------------------------------------------
Fax | 727-845-4595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PERIODONTIST
-----------------------------------------------------
Name | DR. JESSICA STILLEY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 727-847-1239
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DN6888
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DN17194
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------