Healthcare Provider Details

I. General information

NPI: 1891795282
Provider Name (Legal Business Name): PAUL WADLEY HAYCOCK DDS, PC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/11/2006

III. Provider practice location address

6755 E SUPERSTITION SPRINGS BLVD SUITE 102
MESA AZ
85206-4373
US

IV. Provider business mailing address

4202 E BROADWAY #42
MESA AZ
85206-1024
US

V. Phone/Fax

Practice location:
  • Phone: 480-218-7590
  • Fax:
Mailing address:
  • Phone: 480-924-8851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1747
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: