=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629189626
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAYNE ALLEN GREENWOOD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8422 E SHEA BLVD SUITE 104
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-6661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-315-1044
-----------------------------------------------------
Fax | 480-315-1042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8422 E SHEA BLVD SUITE 104
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-6661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-215-1044
-----------------------------------------------------
Fax | 480-315-1042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. KRISTI LYNN GEHR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-315-1044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D5658
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------