=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285044321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD NEIGHBOR HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2014
-----------------------------------------------------
Last Update Date | 06/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 627 E 1ST ST
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45402-1367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-224-3003
-----------------------------------------------------
Fax | 937-224-1771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 627 E. FIRST STREET
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-224-3003
-----------------------------------------------------
Fax | 937-224-1771
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATIONS OFFICER
-----------------------------------------------------
Name | MRS. TIFFANY M. COLLIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-224-3003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------