Healthcare Provider Details

I. General information

NPI: 1962091454
Provider Name (Legal Business Name): HIGHBURY DENTAL MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 W ELLIOT RD STE 101
GILBERT AZ
85233-5141
US

IV. Provider business mailing address

325 S HIGLEY RD STE 130
GILBERT AZ
85296-4703
US

V. Phone/Fax

Practice location:
  • Phone: 602-536-7072
  • Fax:
Mailing address:
  • Phone: 505-850-3769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: EBONIE MARIE GONZALES
Title or Position: CREDENTIALING MNAGAER
Credential:
Phone: 505-850-3769