=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235667403
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKLYN KURTH ORTHODONTICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2017
-----------------------------------------------------
Last Update Date | 05/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1291 E HILLSDALE BLVD STE 200
-----------------------------------------------------
City | FOSTER CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94404-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-525-9440
-----------------------------------------------------
Fax | 650-525-9490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1291 E HILLSDALE BLVD STE 200
-----------------------------------------------------
City | FOSTER CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94404-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-525-9440
-----------------------------------------------------
Fax | 650-525-9490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JACKLYN KURTH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 650-525-9440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 48937
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------