=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649977224
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS FARRELL FARRELL NALE COOK KAPITAN MOHAMED FRANCO WESSEL HOWELL & K
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2023
-----------------------------------------------------
Last Update Date | 02/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 MONTGOMERY DR
-----------------------------------------------------
City | ANDERSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29621-3334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-295-4653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5550 77 CENTER DR STE 320
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28217-0739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-295-4653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CONTRACTING & CREDENTIA
-----------------------------------------------------
Name | JENNIFER RAYLE HOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-295-4653
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------