=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447469879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN W FAUL, DMD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 12/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7435 STATE ROAD 21 SUITE B
-----------------------------------------------------
City | KEYSTONE HEIGHTS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32656-9301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-473-8988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 SW GROVE ST
-----------------------------------------------------
City | KEYSTONE HEIGHTS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32656-9526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-626-7725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN W FAUL
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 321-626-7725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DN08155
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------