=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124494745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LANDMARK SMILES OF SCOTTSDALE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2015
-----------------------------------------------------
Last Update Date | 08/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6920 E SHEA BLVD STE 101
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85254-6180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-991-3244
-----------------------------------------------------
Fax | 480-922-9253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6920 E SHEA BLVD STE 101
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85254-6180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-991-3244
-----------------------------------------------------
Fax | 480-922-9253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AARON J WILDUNG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 480-234-9099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D009244
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------