=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871715359
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREMONT FAMILY DENTISTRY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 05/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 W TOLEDO STREET
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46737-0667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-495-2255
-----------------------------------------------------
Fax | 260-495-9023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 667
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46737-0667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-495-2255
-----------------------------------------------------
Fax | 260-495-9023
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. SUSAN H. MAUK
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 260-495-2255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 012537445 001 7
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------