=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760730782
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. CHRISTOPHER BOB
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2012
-----------------------------------------------------
Last Update Date | 08/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 NW 107TH AVE 3RD FLOOR
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33178-4377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-624-3368
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17050 SW 83RD CT
-----------------------------------------------------
City | PALMETTO BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157-4769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN19396
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DN19396
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------