=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558401992
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROGER DARNELL BARLOW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1499 KENNEDY RD
-----------------------------------------------------
City | TIFTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31794-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-382-7323
-----------------------------------------------------
Fax | 229-382-7375
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1499 KENNEDY RD
-----------------------------------------------------
City | TIFTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31794-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-382-7323
-----------------------------------------------------
Fax | 229-382-7375
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 581814761
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------