Healthcare Provider Details

I. General information

NPI: 1235194655
Provider Name (Legal Business Name): 59TH AVE DENTISTRY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8519 N 59TH AVE
GLENDALE AZ
85302
US

IV. Provider business mailing address

8519 N 59TH AVE
GLENDALE AZ
85302
US

V. Phone/Fax

Practice location:
  • Phone: 623-939-6574
  • Fax: 623-939-3091
Mailing address:
  • Phone: 623-939-6574
  • Fax: 623-939-3091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DON JEAN LAMB
Title or Position: PRESIDENT
Credential: DMD
Phone: 623-939-6574