Healthcare Provider Details

I. General information

NPI: 1457419327
Provider Name (Legal Business Name): HORIZON DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 N BUTTERFIELD RD
CHINO VALLEY AZ
86323
US

IV. Provider business mailing address

432 N BUTTERFIELD RD
CHINO VALLEY AZ
86323
US

V. Phone/Fax

Practice location:
  • Phone: 928-636-1565
  • Fax: 928-636-1164
Mailing address:
  • Phone: 928-636-1565
  • Fax: 928-636-1164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7056
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD6997
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD5634
License Number StateAZ

VIII. Authorized Official

Name: DR. MARK ANTHONY COSTES
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 928-636-1565