=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508219544
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREW E FORMAN ORTHODONTICS,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2016
-----------------------------------------------------
Last Update Date | 01/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7362 E DEL ACERO DR
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-2088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-348-5547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7362 E DEL ACERO DR
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-2088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-348-5547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. ANDREW E FORMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 480-348-5547
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 1625
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------