=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023102183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1801 SOUTHERN VISTA DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 E SOUTHERN AVE SUITE 103
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85204-5258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-892-9000
-----------------------------------------------------
Fax | 480-926-0545
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 E SOUTHERN AVE SUITE 103
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85204-5258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-892-9000
-----------------------------------------------------
Fax | 480-926-0545
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECT OWNER
-----------------------------------------------------
Name | ELWYNN CHAD CAFFALL SR.
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 480-892-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6283
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2561
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6591
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------