MEDICARE: PHOENIX ENDODONTIC CENTER LLC

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	2928	AZ

General Provider Information

NPI Number	:	1144531393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX ENDODONTIC CENTER LLC

Provider Business Mailing Address
First Line	:	13821 N. 35TH DRIVE SUITE 2
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85053
Country	:	US
Telephone Number	:	602-375-8063
Fax Number	:	602-863-3412

Provider Business Practice Location Address
First Line	:	13821 N 35TH DR STE 2
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85053-5541
Country	:	US
Telephone Number	:	602-375-8063
Fax Number	:	602-863-3412

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GARY JOSEPH CORE
Credential	:	D.D.S
Telephone Number	:	602-375-8063

Provider Enumeration Date	:	06/23/2010
Last Update Date	:	06/23/2010

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