Healthcare Provider Details

I. General information

NPI: 1083011316
Provider Name (Legal Business Name): TAYLER FAIRCLOTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 N SCOTTSDALE RD 226
SCOTTSDALE AZ
85251
US

IV. Provider business mailing address

3501 N SCOTTSDALE RD
SCOTTSDALE AZ
85251
US

V. Phone/Fax

Practice location:
  • Phone: 480-941-5005
  • Fax:
Mailing address:
  • Phone: 480-941-5005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number43835
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: