=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417946054
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS BENJAMIN PAYNE D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2005
-----------------------------------------------------
Last Update Date | 05/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 E FAYETTE ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52057-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-927-4746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 E FAYETTE ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52057-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-927-4746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5876
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 08532
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------