=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588636773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FRED WILLIAM CARPENTER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1514 WHITE BEAR AVE
-----------------------------------------------------
City | ST PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55106-1695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-771-7719
-----------------------------------------------------
Fax | 651-776-2595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1514 WHITE BEAR AVE
-----------------------------------------------------
City | ST PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55106-1695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-771-7719
-----------------------------------------------------
Fax | 651-776-2595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 8857
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------