=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821305988
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENIOR DENTAL CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2010
-----------------------------------------------------
Last Update Date | 09/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20120 CENTRAL AVEWEST
-----------------------------------------------------
City | BLOUNTSTOWN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-674-1212
-----------------------------------------------------
Fax | 850-674-2951
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20120 CENTRAL AVEWEST
-----------------------------------------------------
City | BLOUNTSTOWN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-674-1212
-----------------------------------------------------
Fax | 850-674-2951
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTAL HYGIENIST
-----------------------------------------------------
Name | MRS. CASSI LAYNE COPELAND
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 850-674-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------