=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306924097
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALVIN MOTT D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 N OLIVE ST
-----------------------------------------------------
City | ROLLA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65401-3352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-364-7880
-----------------------------------------------------
Fax | 573-364-6473
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11980 COUNTY ROAD 5300
-----------------------------------------------------
City | ROLLA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65401-6786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2003010676
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------