MEDICARE: IRMA IRENE PAULLEY D.D.S.

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	1223D0001X	Public Health Dentistry	D020738	AZ

General Provider Information

NPI Number	:	1104239508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRMA IRENE PAULLEY D.D.S.

Provider Business Mailing Address
First Line	:	44031 PIPELINE PLAZA
Second Line	:
City	:	ASHBURN
State	:	VA
Zip	:	20147
Country	:	US
Telephone Number	:	703-729-9464
Fax Number	:	703-729-1227

Provider Business Practice Location Address
First Line	:	10,000 S. WILMOT RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85734
Country	:	US
Telephone Number	:	520-524-0024
Fax Number	:	520-524-7302

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2014
Last Update Date	:	06/04/2014

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