Healthcare Provider Details

I. General information

NPI: 1285780767
Provider Name (Legal Business Name): CRYSTAL CANYON ENT & FACIAL PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 N RIM DR
FLAGSTAFF AZ
86001-3111
US

IV. Provider business mailing address

1340 N RIM DR
FLAGSTAFF AZ
86001-3111
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-1873
  • Fax: 928-774-5525
Mailing address:
  • Phone: 928-774-1873
  • Fax: 928-774-5525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD3000
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD3000
License Number StateAZ

VIII. Authorized Official

Name: MRS. PAMELA A TAYLOR
Title or Position: OFFICE MANAGER
Credential:
Phone: 928-774-1873