Healthcare Provider Details

I. General information

NPI: 1497486179
Provider Name (Legal Business Name): PHOENIX ARIZONA DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4365 E. PECOS DRIVE BLDG 7 SUITE 106-107
GILBERT AZ
85295
US

IV. Provider business mailing address

14150 W. MCDOWELL RD
GOODYEAR AZ
85395
US

V. Phone/Fax

Practice location:
  • Phone: 602-254-2489
  • Fax:
Mailing address:
  • Phone: 602-254-2489
  • Fax: 623-536-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. GEORGE AYOUB
Title or Position: PART OWNER
Credential: DMD
Phone: 623-536-2040