MEDICARE: DR. BROCH THOMAS D.M.D.

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	22159	FL

General Provider Information

NPI Number	:	1558723213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROCH THOMAS D.M.D.

Provider Business Mailing Address
First Line	:	3021 N 39TH ST APT 2
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-7123
Country	:	US
Telephone Number	:	618-339-0800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1920 S STAPLEY DR STE 105
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-6678
Country	:	US
Telephone Number	:	480-545-5300
Fax Number	:	480-545-5303

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	01/03/2019

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Directions to “ DR. BROCH THOMAS D.M.D.” Practice Location

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