MEDICARE: FLAGSTAFF ENDODONTICS

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	1223E0200X	Endodontics	2197	AZ
2	1223E0200X	Endodontics	6531	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2197	OTHER	AZ	DENTAL LICENSE NO.
2	6531	OTHER	AZ	DENTAL LICENSE NO.

General Provider Information

NPI Number	:	1083799639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLAGSTAFF ENDODONTICS

Provider Business Mailing Address
First Line	:	1600 W UNIVERSITY AVE STE 103
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-3154
Country	:	US
Telephone Number	:	928-774-4400
Fax Number	:	928-774-5436

Provider Business Practice Location Address
First Line	:	1600 W UNIVERSITY AVE STE 103
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-3154
Country	:	US
Telephone Number	:	928-774-4400
Fax Number	:	928-774-5436

Authorized Official
Title or Position	:	RECEPTIONIST
Name	:	MS. TANIA MADDY
Credential	:
Telephone Number	:	928-774-4400

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	01/18/2017

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Directions to “FLAGSTAFF ENDODONTICS ” Practice Location

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