=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962691113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCOTTSDALE DENTAL REHABILITATION CNTR LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2007
-----------------------------------------------------
Last Update Date | 10/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7170 E MCDONALD AVE STE 1
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-946-3333
-----------------------------------------------------
Fax | 480-922-2763
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7170 E MCDONALD AVE STE 1
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-946-3333
-----------------------------------------------------
Fax | 480-922-2763
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD J CROFT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 480-946-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 808
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------