=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669717344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK RICHARD WARREN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2012
-----------------------------------------------------
Last Update Date | 12/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7924 SECOR ROAD BOX 297
-----------------------------------------------------
City | LAMBERTVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48144-0297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-856-3004
-----------------------------------------------------
Fax | 734-215-2323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 297 7924 SECOR ROAD
-----------------------------------------------------
City | LAMBERTVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48144-0297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-856-3004
-----------------------------------------------------
Fax | 734-215-2323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901015738
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30-01-8652
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------