=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942461587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLUMBIANA FAMILY DENTISTRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2008
-----------------------------------------------------
Last Update Date | 06/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 MILDRED ST
-----------------------------------------------------
City | COLUMBIANA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35051-9330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-669-6778
-----------------------------------------------------
Fax | 205-669-6779
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 558 204 MILDRED STREET
-----------------------------------------------------
City | COLUMBIANA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35051-0558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-669-6778
-----------------------------------------------------
Fax | 205-669-6779
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. TIMOTHY DOYLE NETTLES
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 205-669-6778
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5248
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------