MEDICARE: ELWYNN CHAD CAFFALL 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	122300000X	Dentist	AZD6591	AZ

General Provider Information

NPI Number	:	1639370745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELWYNN CHAD CAFFALL D.D.S

Provider Business Mailing Address
First Line	:	1801 E SOUTHERN AVE
Second Line	:	SUITE 101
City	:	MESA
State	:	AZ
Zip	:	85204-5258
Country	:	US
Telephone Number	:	480-892-0060
Fax Number	:	480-892-8806

Provider Business Practice Location Address
First Line	:	1801 E SOUTHERN AVE
Second Line	:	SUITE 101
City	:	MESA
State	:	AZ
Zip	:	85204-5258
Country	:	US
Telephone Number	:	480-892-0060
Fax Number	:	480-892-8806

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

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	07/08/2007

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