=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912374430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTIC FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2015
-----------------------------------------------------
Last Update Date | 09/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 S DIXIE FWY
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32168-7355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-426-2191
-----------------------------------------------------
Fax | 386-426-0195
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 S DIXIE FWY
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32168-7355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-426-2191
-----------------------------------------------------
Fax | 386-426-0195
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEVEN J MITCHELL
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 386-426-2191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------