=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255760120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CULPEPPER FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2013
-----------------------------------------------------
Last Update Date | 11/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 N 13TH ST
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72756-3434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-936-8877
-----------------------------------------------------
Fax | 479-936-8875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 N 13TH ST
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72756-3434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-936-8877
-----------------------------------------------------
Fax | 479-936-8875
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LAURA OSMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-936-8877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3954
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------