=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659149730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | H. WAYNE CHESSER DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2023
-----------------------------------------------------
Last Update Date | 12/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 S SUMMIT AVE STE 2
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-3780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-852-0055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7575 N OUTLOOK LN
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86315-4591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-852-0055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. HARRY WAYNE CHESSER JR.
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 970-852-0055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------