MEDICARE: AZ DENTAL IMPLANT CENTERS 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1346873890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AZ DENTAL IMPLANT CENTERS LLC

Provider Business Mailing Address
First Line	:	7601 E INDIAN BEND RD APT 1050
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85250-4689
Country	:	US
Telephone Number	:	602-386-8972
Fax Number	:

Provider Business Practice Location Address
First Line	:	7102 E ACOMA DR
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85254-2771
Country	:	US
Telephone Number	:	602-386-8972
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	SKY MOORE
Credential	:
Telephone Number	:	602-386-8972

Provider Enumeration Date	:	02/12/2020
Last Update Date	:	02/12/2020

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