=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114581659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STOTT FAMILY & COSMETIC DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2019
-----------------------------------------------------
Last Update Date | 04/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 857 E WARNER RD STE 103
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-3076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-821-4868
-----------------------------------------------------
Fax | 480-821-4724
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 857 E WARNER RD STE 103
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-3076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-821-4868
-----------------------------------------------------
Fax | 480-821-4724
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELDON DEAN STOTT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 480-821-4868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------