=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306988282
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENRY FLOYD PRUETT JR. D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 466 E NINE MILE RD
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32514-1441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-476-2552
-----------------------------------------------------
Fax | 850-479-9861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 466 E NINE MILE RD
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32514-1441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-476-2552
-----------------------------------------------------
Fax | 850-479-9861
-----------------------------------------------------
=====================================================
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 | DN 7581
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------