=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548500309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAYLOR STREET DENTAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2013
-----------------------------------------------------
Last Update Date | 02/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 174 WORTHINGTON ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01103-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-781-7645
-----------------------------------------------------
Fax | 413-736-3476
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 174 WORTHINGTON ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01103-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-781-7645
-----------------------------------------------------
Fax | 413-736-3476
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID I. PECK
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 413-781-7645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN15792
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------