=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609491406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HAPPY TOOTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2020
-----------------------------------------------------
Last Update Date | 06/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 ELM ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47842-1728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-832-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8288 KENAI SPUR HWY
-----------------------------------------------------
City | KENAI
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99611-8901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-756-8960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. COLE WILLIAM STAPP
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 907-756-8960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------