=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265641732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT ADDISON FAUVELL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 11/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 MINEOLA BLVD FL 3
-----------------------------------------------------
City | MINEOLA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11501-3959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-294-9696
-----------------------------------------------------
Fax | 516-294-3531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 134 MINEOLA BLVD
-----------------------------------------------------
City | MINEOLA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-294-9696
-----------------------------------------------------
Fax | 516-294-3531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 050443
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------