=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578936977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA INMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2015
-----------------------------------------------------
Last Update Date | 11/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2222 E HIGHLAND AVE STE 320
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-4879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-956-9560
-----------------------------------------------------
Fax | 602-956-9977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2222 E. HIGHLAND STE#320
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-956-9560
-----------------------------------------------------
Fax | 602-956-9977
-----------------------------------------------------
=====================================================
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 | 4204
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------