Healthcare Provider Details

I. General information

NPI: 1164722021
Provider Name (Legal Business Name): COUNTRY CLUB DENTAL MANAGEMENT CO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4704 E SOUTHERN AVE SUITE #1
MESA AZ
85206-2737
US

IV. Provider business mailing address

4704 E SOUTHERN AVE
MESA AZ
85206-2737
US

V. Phone/Fax

Practice location:
  • Phone: 480-889-9457
  • Fax: 480-889-9493
Mailing address:
  • Phone: 480-889-9457
  • Fax: 480-889-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD07819
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD07819
License Number StateAZ

VIII. Authorized Official

Name: DR. LAWRENCE GEORGE GROOP
Title or Position: DIRECTOR
Credential: DMD
Phone: 480-889-9457