Healthcare Provider Details

I. General information

NPI: 1215953161
Provider Name (Legal Business Name): LEGACY DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18205 N 51ST AVE STE 101
GLENDALE AZ
85308-1491
US

IV. Provider business mailing address

POC MANAGEMENT LLC 3000 W WARNER AVE
SANTA ANA CA
92704
US

V. Phone/Fax

Practice location:
  • Phone: 602-993-4200
  • Fax: 602-993-4222
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberD4729
License Number StateAZ

VIII. Authorized Official

Name: LOUIS CORE
Title or Position: DDS
Credential:
Phone: 602-993-4200