=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891907630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACACIA DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 07/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7517 S. MCCLINTOCK DR. SUITE 1006
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85283-5011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-831-7775
-----------------------------------------------------
Fax | 480-831-8108
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1321 E KRISTA WAY
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85284-1658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-831-7775
-----------------------------------------------------
Fax | 480-831-8108
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY ARTHUR MATHEWS
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 480-831-7775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4342
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 4342
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------