MEDICARE: PEORIA DENTAL CENTER GROUP, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1760756209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEORIA DENTAL CENTER GROUP, LLC

Provider Business Mailing Address
First Line	:	8914 N 91ST AVE STE 115
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-8390
Country	:	US
Telephone Number	:	623-877-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	8914 N 91ST AVE STE 115
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-8390
Country	:	US
Telephone Number	:	623-877-5700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RASOUL SALIM
Credential	:
Telephone Number	:	623-877-5700

Provider Enumeration Date	:	03/01/2012
Last Update Date	:	03/01/2012

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Directions to “PEORIA DENTAL CENTER GROUP, LLC ” Practice Location

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