=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588051395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 14TH STREET DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2015
-----------------------------------------------------
Last Update Date | 04/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 14TH ST SUITE C
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75074-6426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-808-1970
-----------------------------------------------------
Fax | 855-731-5147
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 674330
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75267-4330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-808-1970
-----------------------------------------------------
Fax | 855-731-5147
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CRAIG F COPELAND
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 940-808-1970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25735
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------