=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285849075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTALCENTRE OF WEST FL. PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 09/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 SOUTH 7TH AVE
-----------------------------------------------------
City | WAUCHULA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-773-9852
-----------------------------------------------------
Fax | 863-773-5005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 SOUTH 7TH AVE
-----------------------------------------------------
City | WAUCHULA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-773-9852
-----------------------------------------------------
Fax | 863-773-5005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. JOSEPH W HOLMES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 863-773-9852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN 10682
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------