=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548747090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOOSSE FAMILY ORTHODONTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2018
-----------------------------------------------------
Last Update Date | 12/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1116 PROFESSIONAL DR STE A
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-3378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-229-4181
-----------------------------------------------------
Fax | 757-221-7233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4068 AMBASSADOR CIR
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23188-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-876-9593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MATTHEW WALLACE JOOSSE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 757-876-9593
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------