Provider Demographics
NPI:1083308209
Name:TAYSOM, TOD CORWIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TOD
Middle Name:CORWIN
Last Name:TAYSOM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 N MILLER RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-2259
Mailing Address - Country:US
Mailing Address - Phone:480-254-8689
Mailing Address - Fax:
Practice Address - Street 1:6702 W CAMELBACK RD STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-6324
Practice Address - Country:US
Practice Address - Phone:602-635-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011818122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist