Healthcare Provider Details

I. General information

NPI: 1093082679
Provider Name (Legal Business Name): ARIZONA TMJ AND SLEEP CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2011
Last Update Date: 11/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 W UNION HILLS DR
GLENDALE AZ
85308-8067
US

IV. Provider business mailing address

PO BOX 10730
GLENDALE AZ
85318-0730
US

V. Phone/Fax

Practice location:
  • Phone: 602-843-0010
  • Fax: 602-843-5554
Mailing address:
  • Phone: 602-843-0010
  • Fax: 602-843-5554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3276
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK RORY CHASE
Title or Position: PRESIDENT
Credential: DDS
Phone: 602-843-0010