=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265752695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | F&S DENTAL SPECIALISTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2010
-----------------------------------------------------
Last Update Date | 06/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3125 CAPE HORN RD
-----------------------------------------------------
City | RED LION
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17356-9071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-417-6263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3125 CAPE HORN RD
-----------------------------------------------------
City | RED LION
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17356-9071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-417-6263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DANIEL LLOYD WILLIAM FISHEL
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 717-417-6263
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DS036144
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DS036144
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------