=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619544749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARRY SQUIRE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2021
-----------------------------------------------------
Last Update Date | 06/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 INNOVATION DR STE 302
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-3866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-436-0026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 INNOVATION DR STE 302
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-3866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-436-0026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. HARRY WOOTEN SQUIRE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 434-594-7453
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------