Basic Information
| Provider Information | |||||||||
| NPI: | 1346530417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESCOTT MODERN DENTISTRY, LLP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRESCOTT MODERN DENTISTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 GAIL GARDNER WAY | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863053499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287778550 | ||||||||
| FaxNumber: | 9284430142 | ||||||||
| Practice Location | |||||||||
| Address1: | 2860 MICHELLE FL 2 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926061008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143682077 | ||||||||
| FaxNumber: | 7143682092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 04/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | FAIRCHILD | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 9287778550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.