=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245738137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WARREN ALYSE DENTAL GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2018
-----------------------------------------------------
Last Update Date | 01/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 CHRISTIE DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-5534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-634-6110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 824 FAY ST
-----------------------------------------------------
City | MANDEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70448-6531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-272-0772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DANIEL WARREN ANTEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 318-272-0772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------