=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972984789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATHENA VU DDS PLLC 2
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2015
-----------------------------------------------------
Last Update Date | 06/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 SOUTH TRYON STREET SUITE M4
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-375-7711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 S TRYON SUITE M4
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28285-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-375-7711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | ATHENA VU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 704-500-1355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------