=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275993016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOE SCHMOE DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2016
-----------------------------------------------------
Last Update Date | 03/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 999 PEACHTREE ST NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-3915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 111-222-3344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 999 PEACHTREE ST NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-3915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOE SCHMOE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 111-222-3344
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1234546677
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------