=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366612616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PITTSBORO FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2008
-----------------------------------------------------
Last Update Date | 03/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 N MAPLE ST
-----------------------------------------------------
City | PITTSBORO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46167-9164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-892-4994
-----------------------------------------------------
Fax | 317-892-4409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 314
-----------------------------------------------------
City | PITTSBORO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46167-0314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-892-4994
-----------------------------------------------------
Fax | 317-892-4409
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. STEVEN LEE RICHWINE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 317-892-4994
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 7056
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------