=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942219597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NADENE J TIPTON DDS, MS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6102 82ND ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-3690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-792-2288
-----------------------------------------------------
Fax | 806-792-2768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6102 82ND ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-3690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-792-2288
-----------------------------------------------------
Fax | 806-792-2768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL COORDINATOR
-----------------------------------------------------
Name | MRS. JENNIFER LAWLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-792-2288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 16972
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------