=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467747303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA PETITE DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2011
-----------------------------------------------------
Last Update Date | 06/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 CARMICHAEL RD STE 200
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-8271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-527-3848
-----------------------------------------------------
Fax | 855-457-3329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 CARMICHAEL RD STE 200
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-8271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-527-3848
-----------------------------------------------------
Fax | 855-457-3329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. ANDY MANCINI
-----------------------------------------------------
Credential | DMD, MBA
-----------------------------------------------------
Telephone | 855-527-3848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 6499-015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------