MEDICARE: NORTH PHOENIX PEDIATRIC DENTISTRY, 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	261QD0000X	Dental Clinic/Center	2542	AZ

General Provider Information

NPI Number	:	1871098269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH PHOENIX PEDIATRIC DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	1526 W GLENDALE AVE STE 103
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-8576
Country	:	US
Telephone Number	:	602-864-1080
Fax Number	:	602-864-7036

Provider Business Practice Location Address
First Line	:	1526 W GLENDALE AVE STE 103
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-8576
Country	:	US
Telephone Number	:	602-864-1080
Fax Number	:	602-864-7036

Authorized Official
Title or Position	:	PRESIDENT/PEDIATRIC DENTIST
Name	:	WILLIAM JOSEPH HEIMANN
Credential	:	DDS
Telephone Number	:	602-864-1080

Provider Enumeration Date	:	03/27/2018
Last Update Date	:	03/27/2018

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