=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780978353
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITINSVILLE FAMILY DENTISTRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2011
-----------------------------------------------------
Last Update Date | 06/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 PROSPECT ST
-----------------------------------------------------
City | WHITINSVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01588-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-234-8107
-----------------------------------------------------
Fax | 508-234-2913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 PROSPECT ST
-----------------------------------------------------
City | WHITINSVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01588-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-234-8107
-----------------------------------------------------
Fax | 508-234-2913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JASON R TUBO
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 508-234-8107
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22148
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------