=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558101501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLEIGH RAIN DAVIDSON DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2024
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PO BOX 457
-----------------------------------------------------
City | GANADO
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86505-0457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-755-4850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6931 W DEL RIO ST
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85226-1696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-644-0474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D012156
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------