=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881099802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDERICK DANIELS,DDS,FAMILY DENTISTRY,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2014
-----------------------------------------------------
Last Update Date | 09/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 GOOSE LN
-----------------------------------------------------
City | TOLLAND
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06084-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-875-6269
-----------------------------------------------------
Fax | 860-870-5606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 GOOSE LN
-----------------------------------------------------
City | TOLLAND
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06084-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-875-6269
-----------------------------------------------------
Fax | 860-870-5606
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. FREDERICK DANIELS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 860-875-6269
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 005030
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------