MEDICARE: 1801 SOUTHERN VISTA DENTAL CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6283	AZ
2	122300000X	Dentist	2561	AZ
3	122300000X	Dentist	6591	AZ

General Provider Information

NPI Number	:	1023102183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1801 SOUTHERN VISTA DENTAL CARE

Provider Business Mailing Address
First Line	:	1801 E SOUTHERN AVE
Second Line	:	SUITE 103
City	:	MESA
State	:	AZ
Zip	:	85204-5258
Country	:	US
Telephone Number	:	480-892-9000
Fax Number	:	480-926-0545

Provider Business Practice Location Address
First Line	:	1801 E SOUTHERN AVE
Second Line	:	SUITE 103
City	:	MESA
State	:	AZ
Zip	:	85204-5258
Country	:	US
Telephone Number	:	480-892-9000
Fax Number	:	480-926-0545

Authorized Official
Title or Position	:	DIRECT OWNER
Name	:	ELWYNN CHAD CAFFALL SR.
Credential	:	DDS
Telephone Number	:	480-892-9000

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	08/22/2020

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