=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548335433
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VAUGHN ELLIOT BRUMMER D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2006
-----------------------------------------------------
Last Update Date | 02/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 PRIDE AVENUE
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42431-9108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-821-7386
-----------------------------------------------------
Fax | 270-821-7401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 PRIDE AVENUE
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42431-9108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-821-7386
-----------------------------------------------------
Fax | 270-821-7401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 7957
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 12010912A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------