=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710311386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID R TROST DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2013
-----------------------------------------------------
Last Update Date | 08/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2604 LINCOLN TRL
-----------------------------------------------------
City | TAYLORVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62568-9718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 39-382-6404
-----------------------------------------------------
Fax | 309-382-6405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 RADIO CITY DR STE C
-----------------------------------------------------
City | NORTH PEKIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61554-1570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-382-6404
-----------------------------------------------------
Fax | 309-382-6405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID R TROST
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 309-382-6404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.016607
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------