Healthcare Provider Details

I. General information

NPI: 1609730779
Provider Name (Legal Business Name): FAIRWAY DENTAL AZ PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 VILLAGE PARKWAY SUITE 203/204
LITCHFIELD PARK AZ
85340
US

IV. Provider business mailing address

250 VILLAGE PARKWAY SUITE 203/204
LITCHFIELD PARK AZ
85340
US

V. Phone/Fax

Practice location:
  • Phone: 623-428-1808
  • Fax: 623-428-0690
Mailing address:
  • Phone: 623-428-1808
  • Fax: 623-428-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN EWELL
Title or Position: OWNER/DENIST
Credential: D.M.D.
Phone: 623-428-1808