=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730624115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRINGFIELD DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2016
-----------------------------------------------------
Last Update Date | 12/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 452 MERCANTILE PLACE
-----------------------------------------------------
City | FORT MILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-548-0005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 452 MERCANTILE PLACE
-----------------------------------------------------
City | FORT MILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-548-0005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARK KLOPENSTINE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 803-548-0005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4508
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------