=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952824047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY & IMPLANT DENTISTRY HUNTINGBURG LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 N CHESTNUT ST
-----------------------------------------------------
City | HUNTINGBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47542-9341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-683-5810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1411 N CHESTNUT ST
-----------------------------------------------------
City | HUNTINGBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47542-9341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-683-5810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ALAN PAUL FRIZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 812-683-5810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 12008787A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------