=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295019115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2011
-----------------------------------------------------
Last Update Date | 10/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4110 BUCKEYE PKWY
-----------------------------------------------------
City | GROVE CITY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43123-8175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-539-0765
-----------------------------------------------------
Fax | 614-522-6767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4110 BUCKEYE PKWY
-----------------------------------------------------
City | GROVE CITY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43123-8175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-539-0765
-----------------------------------------------------
Fax | 614-522-6767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL LEE SMITH JR.
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 614-759-4746
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 30022270
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------