=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306111349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NELSON RIDGE FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2012
-----------------------------------------------------
Last Update Date | 03/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 LARAWAY RD
-----------------------------------------------------
City | NEW LENOX
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60451-2694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-524-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 LARAWAY RD
-----------------------------------------------------
City | NEW LENOX
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60451-2694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PAUL E ETCHISON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 815-524-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 019.027903
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------