=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710039482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK D. PABST FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2799 CHARLES BLVD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-5933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-355-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2799 CHARLES BLVD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-5933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-355-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK D PABST III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-355-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6249
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------