=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649464850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY C, HARVEY D.D.S., SC.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2007
-----------------------------------------------------
Last Update Date | 08/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1550 30TH AVE S
-----------------------------------------------------
City | MOORHEAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56560-5150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-236-1322
-----------------------------------------------------
Fax | 218-236-0719
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1550 30TH AVE S
-----------------------------------------------------
City | MOORHEAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56560-5150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-236-1322
-----------------------------------------------------
Fax | 218-236-0719
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFREY CLYDE HARVEY
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 218-236-1322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | D10196
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------