=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881986008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRANIOFACIAL PAIN ASSOCIATES, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2011
-----------------------------------------------------
Last Update Date | 05/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 MARTIN DR
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76021-5993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-283-0025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 MARTIN DR
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76021-5993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-283-0025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. JAMES RICHARD POLSON
-----------------------------------------------------
Credential | R.PH., D.D.S.
-----------------------------------------------------
Telephone | 817-283-0025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 14974
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------