=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811486517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIRECT DENTAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2018
-----------------------------------------------------
Last Update Date | 08/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 MILL RIVER ST STE UL2
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-890-9191
-----------------------------------------------------
Fax | 203-890-9193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 MILL RIVER ST STE UL2
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-890-9191
-----------------------------------------------------
Fax | 203-890-9193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. EMIL BLANK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 203-890-9191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 11954
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------