=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639290141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWRENCE RICHARD VOSS D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 02/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 514 NA WA TA AVE
-----------------------------------------------------
City | MOUNT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-3624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-394-5304
-----------------------------------------------------
Fax | 847-394-5304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 NA WA TA AVE
-----------------------------------------------------
City | MOUNT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-3624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-394-5304
-----------------------------------------------------
Fax | 847-394-5304
-----------------------------------------------------
=====================================================
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 | 021001145
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------