Healthcare Provider Details

I. General information

NPI: 1063005049
Provider Name (Legal Business Name): DENTAL SPECIALTY GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4435 E BROADWAY RD STE 7
MESA AZ
85206-2012
US

IV. Provider business mailing address

3658 E MORRISON RANCH PKWY
GILBERT AZ
85296-1816
US

V. Phone/Fax

Practice location:
  • Phone: 480-471-8480
  • Fax: 480-654-0705
Mailing address:
  • Phone: 480-239-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BENNETT MANKIN
Title or Position: PRESIDENT
Credential:
Phone: 480-239-2088