=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538477484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARNES AND MCDONNELL PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2010
-----------------------------------------------------
Last Update Date | 09/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1440 REED CANAL RD SUITE 103
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32129-9418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-760-0550
-----------------------------------------------------
Fax | 386-756-1009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1440 REED CANAL RD SUITE 103
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32129-9418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-760-0550
-----------------------------------------------------
Fax | 386-756-1009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. SEAN T. MCDONNELL
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 386-760-0550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------