=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801251616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN W BULL DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2015
-----------------------------------------------------
Last Update Date | 12/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 228 N CHERRY ST
-----------------------------------------------------
City | FRUITA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81521-2101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-243-2855
-----------------------------------------------------
Fax | 970-256-9467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2226 DOGWOOD CT
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81506-8402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-243-2855
-----------------------------------------------------
Fax | 970-256-9467
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | DR. JOHN WILLIAM BULL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 970-243-2855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN00000167
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------