MEDICARE: CIVANO DENTAL CARE PC

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	261QD0000X	Dental Clinic/Center	4821	AZ

General Provider Information

NPI Number	:	1023432820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CIVANO DENTAL CARE PC

Provider Business Mailing Address
First Line	:	10501 E SEVEN GENERATIONS WAY
Second Line	:	155
City	:	TUCSON
State	:	AZ
Zip	:	85747-5828
Country	:	US
Telephone Number	:	520-838-0302
Fax Number	:	520-838-0982

Provider Business Practice Location Address
First Line	:	10501 E SEVEN GENERATIONS WAY
Second Line	:	155
City	:	TUCSON
State	:	AZ
Zip	:	85747-5828
Country	:	US
Telephone Number	:	520-838-0302
Fax Number	:	520-838-0982

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CHARLES E PICK
Credential	:	D.D.S.
Telephone Number	:	529-838-0302

Provider Enumeration Date	:	02/13/2014
Last Update Date	:	02/13/2014

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