=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508958273
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID DIBBLE DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2550 N MAIN STREET
-----------------------------------------------------
City | CENTRAL LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-544-8115
-----------------------------------------------------
Fax | 231-544-6012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 457 2550 N MAIN STREET
-----------------------------------------------------
City | CENTRAL LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-544-8115
-----------------------------------------------------
Fax | 231-544-6012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID LEE DIBBLE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 231-544-8115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901013248
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------