=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417265547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DPWP, P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2010
-----------------------------------------------------
Last Update Date | 09/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 VILLAGE CREEK DR
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-4449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-380-8105
-----------------------------------------------------
Fax | 972-380-0137
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 VILLAGE CREEK DR
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-4449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-380-8105
-----------------------------------------------------
Fax | 972-380-0137
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JESSICA SEMPLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-380-8105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 15768
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------