=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972793339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R. KEITH CALVERT, DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2007
-----------------------------------------------------
Last Update Date | 07/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 AARON DR
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35215-8201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-836-0877
-----------------------------------------------------
Fax | 205-836-5751
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 313 AARON DR
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35215-8201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-836-0877
-----------------------------------------------------
Fax | 205-836-5751
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. RUSSEL KEITH CALVERT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 205-836-0877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 2703
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------