=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295146413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KALAMAZOO PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2014
-----------------------------------------------------
Last Update Date | 09/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 WHITES RD
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49008-2872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-343-5386
-----------------------------------------------------
Fax | 269-343-0913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 WHITES RD
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49008-2872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-343-5386
-----------------------------------------------------
Fax | 269-343-0913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. RYAN MICHAEL BASLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 269-343-5386
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------