=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417347154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PETERSBURG SMILE CENTER, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2015
-----------------------------------------------------
Last Update Date | 02/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 MEDICAL PARK BLVD SUITE E
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-9283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-732-8800
-----------------------------------------------------
Fax | 804-732-8801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34 MEDICAL PARK BLVD SUITE E
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-9283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-732-8800
-----------------------------------------------------
Fax | 804-732-8801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NICOLE TOWANA BARBOUR
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 804-732-8800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------