=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780011213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HENDERSONVILLE DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2013
-----------------------------------------------------
Last Update Date | 09/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 687 BLYTHE STREET CT STE A
-----------------------------------------------------
City | HENDERSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28739-4054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-692-3933
-----------------------------------------------------
Fax | 828-692-9946
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 687 BLYTHE STREET CT STE A
-----------------------------------------------------
City | HENDERSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28739-4054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-692-3933
-----------------------------------------------------
Fax | 828-692-9946
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | CLAIRE L BLACK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 828-692-3933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 9285
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------