=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851557151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENTLE TOUCH DENTISTRY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2008
-----------------------------------------------------
Last Update Date | 08/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2155 LOCH RANE BLVD
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-5719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-272-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2155 LOCH RANE BLVD
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-5719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-272-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | V.P.
-----------------------------------------------------
Name | MR. CARL G. STOUTAMIRE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-272-2828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN13497
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------