=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972979128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMERVILLE AND NORMAN PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2015
-----------------------------------------------------
Last Update Date | 08/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 QUEENS RD SUITE 310
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-3253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-334-5306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 QUEENS RD SUITE 310
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-3253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-334-5306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM SUMMERVILLE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 704-965-7988
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------