=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750568416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL O. GIVENS, DDS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2008
-----------------------------------------------------
Last Update Date | 01/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6608 E HARRIS BLVD SUITE G
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-5127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-536-2299
-----------------------------------------------------
Fax | 704-537-3562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6608 E HARRIS BLVD SUITE G
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-5127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-536-2299
-----------------------------------------------------
Fax | 704-537-3562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL ODELL GIVENS
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 704-536-2299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 5082
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------