Healthcare Provider Details

I. General information

NPI: 1720748049
Provider Name (Legal Business Name): RADIANT DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19251 E OASIS DR
BLACK CANYON CITY AZ
85324-8878
US

IV. Provider business mailing address

19251 E OASIS DR
BLACK CANYON CITY AZ
85324-8878
US

V. Phone/Fax

Practice location:
  • Phone: 623-526-2607
  • Fax:
Mailing address:
  • Phone: 623-526-2607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BRENDA LIANA ARMES
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 818-577-7367