MEDICARE: MARK A. GAONA, D.D.S., P.C.

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	4159	AZ

General Provider Information

NPI Number	:	1669535639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK A. GAONA, D.D.S., P.C.

Provider Business Mailing Address
First Line	:	18555 N 79TH AVE
Second Line	:	SUITE B-107
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8370
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18555 N 79TH AVE
Second Line	:	SUITE B-107
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8370
Country	:	US
Telephone Number	:	623-486-4700
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK A. GAONA
Credential	:	D.D.S.
Telephone Number	:	623-486-4700

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	07/01/2008

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