=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376562033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK J FLANNAGAN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 741 12TH ST
-----------------------------------------------------
City | TELL CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47586-1728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-547-3478
-----------------------------------------------------
Fax | 812-547-3479
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 741 12TH ST
-----------------------------------------------------
City | TELL CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47586-1728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-547-3478
-----------------------------------------------------
Fax | 812-547-3479
-----------------------------------------------------
=====================================================
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 | 12009116A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------