=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558670471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORWICH SMILES FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2010
-----------------------------------------------------
Last Update Date | 09/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 514 W MAIN ST
-----------------------------------------------------
City | NORWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06360-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-889-5166
-----------------------------------------------------
Fax | 860-887-8254
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 W MAIN ST
-----------------------------------------------------
City | NORWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06360-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-889-5166
-----------------------------------------------------
Fax | 860-887-8254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PART OWNER
-----------------------------------------------------
Name | DR. PHILIP T DOYLE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 860-889-5166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------