Healthcare Provider Details

I. General information

NPI: 1033690169
Provider Name (Legal Business Name): PREVENTATIVE DENTAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
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: 162-344-4232
  • Fax:
Mailing address:
  • Phone: 162-344-4232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SCOTT W HIRSBRUNNER
Title or Position: OWNER
Credential: DMD
Phone: 623-444-2322