Healthcare Provider Details

I. General information

NPI: 1710419353
Provider Name (Legal Business Name): HARRISON DANIEL FRYBERG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2017
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 S WATSON RD STE 218
BUCKEYE AZ
85326-3470
US

IV. Provider business mailing address

7160 E KIERLAND BLVD APT 811
SCOTTSDALE AZ
85254-2995
US

V. Phone/Fax

Practice location:
  • Phone: 623-304-7701
  • Fax:
Mailing address:
  • Phone: 310-595-4903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number102128
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD011035
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD011035
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number102128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: