=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023523396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FATTAH FAMILY DENTISTRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2017
-----------------------------------------------------
Last Update Date | 12/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8055 N VIA DE NEGOCIO
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-4313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-607-6937
-----------------------------------------------------
Fax | 480-607-6973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7961 E SOFTWIND DR
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-3467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-361-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / GENERAL DENTIST
-----------------------------------------------------
Name | DR. KAMRAN FATTAH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 503-330-2847
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | D009597
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------