=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639209075
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS EDWIN DUNN II D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 W NORTH ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47371-1136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-726-8007
-----------------------------------------------------
Fax | 260-726-2505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 W NORTH ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47371-1136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-726-8007
-----------------------------------------------------
Fax | 260-726-2505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12009010
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------