=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609349612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SDS-BILL OWENS PKWY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2019
-----------------------------------------------------
Last Update Date | 01/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 DOCTOR CIR
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75605-5050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-757-2495
-----------------------------------------------------
Fax | 903-757-3707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 DOCTOR CIR
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75605-5050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-757-2495
-----------------------------------------------------
Fax | 903-757-3707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. SAMUEL CHRISTOPHER MACK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 903-236-4050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------