=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639244494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD A AMLEY D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 09/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5753 FIRST AVE N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-7913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-381-1062
-----------------------------------------------------
Fax | 727-343-8337
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5753 FIRST AVE N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-7913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-381-1062
-----------------------------------------------------
Fax | 727-343-8337
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN4233
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------