Healthcare Provider Details

I. General information

NPI: 1043043565
Provider Name (Legal Business Name): SAMUEL TAMAYO FERNANDEZ JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SAM TAMAYO FERNANDEZ JR. DDS

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 W AGUA FRIA FWY STE 8A
PHOENIX AZ
85027-3901
US

IV. Provider business mailing address

7900 E PRINCESS DR APT 2249
SCOTTSDALE AZ
85255-5867
US

V. Phone/Fax

Practice location:
  • Phone: 623-255-3390
  • Fax:
Mailing address:
  • Phone: 224-436-2570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012283
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: