=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588833792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY DENTISTRY OF SANDUSKY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2008
-----------------------------------------------------
Last Update Date | 10/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 595 S SANDUSKY RD
-----------------------------------------------------
City | SANDUSKY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48471-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-648-2522
-----------------------------------------------------
Fax | 810-648-1916
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 71
-----------------------------------------------------
City | SANDUSKY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48471-0071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-648-2522
-----------------------------------------------------
Fax | 810-648-1916
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RECEPTIONIST
-----------------------------------------------------
Name | MRS. DEBBIE LEE LAMM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-648-2522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------