MEDICARE: DENTAMED MANAGEMENT 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1205432796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAMED MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	4517 W BLUEFIELD AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-1513
Country	:	US
Telephone Number	:	818-577-7367
Fax Number	:

Provider Business Practice Location Address
First Line	:	4517 W BLUEFIELD AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-1513
Country	:	US
Telephone Number	:	818-577-7367
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRENDA LIANA MACSWAN
Credential	:
Telephone Number	:	818-577-7367

Provider Enumeration Date	:	12/09/2020
Last Update Date	:	12/15/2020

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