=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083011316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLER FAIRCLOTH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2014
-----------------------------------------------------
Last Update Date | 12/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3501 N SCOTTSDALE RD 226
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-941-5005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3501 N SCOTTSDALE RD
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-941-5005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | 43835
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------