Healthcare Provider Details

I. General information

NPI: 1508418625
Provider Name (Legal Business Name): AZ GW ORTHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3329 E BASELINE RD
GILBERT AZ
85234-2633
US

IV. Provider business mailing address

2218 E WILLIAMS FIELD RD STE 260
GILBERT AZ
85295-0779
US

V. Phone/Fax

Practice location:
  • Phone: 480-632-6868
  • Fax:
Mailing address:
  • Phone: 480-632-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: EBONIE MARIE GONZALES
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 505-553-3607