MEDICARE: WESTERN DENTAL OF ARIZONA, INC.

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1215073168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN DENTAL OF ARIZONA, INC.

Provider Business Mailing Address
First Line	:	530 S MAIN ST
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4525
Country	:	US
Telephone Number	:	714-480-3000
Fax Number	:	714-571-3560

Provider Business Practice Location Address
First Line	:	3922 N ORACLE RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85705-3276
Country	:	US
Telephone Number	:	520-293-0590
Fax Number	:	520-293-0607

Authorized Official
Title or Position	:	PPOCOORDINATOR
Name	:	CINDY E AVALOS
Credential	:
Telephone Number	:	714-480-3000

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	08/22/2020

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