=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326212374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEWTON FAMILY DENTAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2008
-----------------------------------------------------
Last Update Date | 04/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 S MAIN ST
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39345-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-683-6567
-----------------------------------------------------
Fax | 601-683-7555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 S MAIN ST
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39345-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-683-6567
-----------------------------------------------------
Fax | 601-683-7555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. JOHN B HARRISON
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 601-683-6567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 2179-85
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------