Healthcare Provider Details

I. General information

NPI: 1023102183
Provider Name (Legal Business Name): 1801 SOUTHERN VISTA DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E SOUTHERN AVE SUITE 103
MESA AZ
85204-5258
US

IV. Provider business mailing address

1801 E SOUTHERN AVE SUITE 103
MESA AZ
85204-5258
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-9000
  • Fax: 480-926-0545
Mailing address:
  • Phone: 480-892-9000
  • Fax: 480-926-0545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6283
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2561
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6591
License Number StateAZ

VIII. Authorized Official

Name: ELWYNN CHAD CAFFALL SR.
Title or Position: DIRECT OWNER
Credential: DDS
Phone: 480-892-9000