=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861736951
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELAWARE ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2012
-----------------------------------------------------
Last Update Date | 12/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 580 PENNSYLVANIA AVE
-----------------------------------------------------
City | DELAWARE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43015-1523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-417-4985
-----------------------------------------------------
Fax | 740-417-9312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 580 PENNSYLVANIA AVE
-----------------------------------------------------
City | DELAWARE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43015-1523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-417-4985
-----------------------------------------------------
Fax | 740-417-9312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAMES A HOMON
-----------------------------------------------------
Credential | DDS, MS, PC
-----------------------------------------------------
Telephone | 740-417-4985
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 30.020832
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------