=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851796262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMP-MACK ENTERPRISES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2014
-----------------------------------------------------
Last Update Date | 10/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 N JEFFERSON AVE
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75455-3261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-577-1123
-----------------------------------------------------
Fax | 903-577-1125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3004 H G MOSLEY PKWY
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75605-2948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-758-3444
-----------------------------------------------------
Fax | 903-758-1967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAMES ANDREW MACK
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 903-758-3444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 14659
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------