MEDICARE: GREENFILED LAKE FAMILY DENTISTRY

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

General Provider Information

NPI Number	:	1366725731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENFILED LAKE FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	7502 E PINNACLE PEAK RD
Second Line	:	SUITE B119
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85255-6168
Country	:	US
Telephone Number	:	480-538-0777
Fax Number	:	480-538-8666

Provider Business Practice Location Address
First Line	:	7502 E PINNACLE PEAK RD
Second Line	:	SUITE B119
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85255-6168
Country	:	US
Telephone Number	:	480-538-0777
Fax Number	:	480-538-8666

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GIRIJA NADARAJAN
Credential	:	DDS
Telephone Number	:	480-558-7556

Provider Enumeration Date	:	09/22/2011
Last Update Date	:	09/22/2011

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