Healthcare Provider Details

I. General information

NPI: 1326172842
Provider Name (Legal Business Name): TOMMIE GLENN B. DECANO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 E MCKELLIPS RD
MESA AZ
85203-2865
US

IV. Provider business mailing address

15801 S 48TH ST # 1074
PHOENIX AZ
85048-0807
US

V. Phone/Fax

Practice location:
  • Phone: 480-649-1949
  • Fax: 480-649-0617
Mailing address:
  • Phone: 909-919-4334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6306
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: