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NPI Code Detail

MEDICARE: MESA MODERN DENTISTRY, LLP

MEDICARE: MESA MODERN DENTISTRY, LLP
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
11223G0001XGeneral Practice Dentistry

General Provider Information

NPI Number : 1477821460
Entity Type Code : Organization
Provider Name (Legal Business Name) : MESA MODERN DENTISTRY, LLP
Provider Business Mailing Address
First Line : 2860 MICHELLE FL 2
Second Line :
City : IRVINE
State : CA
Zip : 92606-1008
Country : US
Telephone Number : 714-368-2077
Fax Number : 714-368-2092
Provider Business Practice Location Address
First Line : 3440 E BASELINE RD STE 106
Second Line :
City : MESA
State : AZ
Zip : 85204-7247
Country : US
Telephone Number : 480-926-2350
Fax Number : 480-926-2366
Authorized Official
Title or Position : OWNER DOCTOR
Name : DR. CARL C FAIRCHILD
Credential : DDS
Telephone Number : 480-926-2350
Provider Enumeration Date : 12/06/2011
Last Update Date : 12/06/2011

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Directions to “MESA MODERN DENTISTRY, LLP ” Practice Location

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