=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386009884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENNIS PAUL NUTTER DDS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2015
-----------------------------------------------------
Last Update Date | 12/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3694 HILBORN RD STE 100
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94534-7994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-422-5444
-----------------------------------------------------
Fax | 707-422-1613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3694 HILBORN RD STE 100
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94534-7994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-422-5444
-----------------------------------------------------
Fax | 707-422-1613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DENNIS PAUL NUTTER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 707-422-5444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 28054
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------