=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669260519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALAWAY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2025
-----------------------------------------------------
Last Update Date | 04/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2111 E HIGHLAND AVE # B105
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-4741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-955-7788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2124 E PARK VIEW LN
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85024-5302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-942-9219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AUSTIN CALAWAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-942-9219
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------