=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740524446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A PLUS SMILES CHILDREN'S DENTISTRY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2012
-----------------------------------------------------
Last Update Date | 09/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2335 STATE AVE SUITE A
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-4398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-215-7100
-----------------------------------------------------
Fax | 850-215-7002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2406 SAINT ANDREWS BLVD
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-2169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-215-7100
-----------------------------------------------------
Fax | 850-215-7002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEPHEN ERIC BERRY
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 850-481-1969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DN16280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------