Healthcare Provider Details

I. General information

NPI: 1063649192
Provider Name (Legal Business Name): EAST VALLEY PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6755 E SUPERSTITION SPRINGS BLVD STE. 102
MESA AZ
85206-4373
US

IV. Provider business mailing address

6755 E SUPERSTITION SPRINGS BLVD STE. 102
MESA AZ
85206-4373
US

V. Phone/Fax

Practice location:
  • Phone: 480-218-7590
  • Fax: 480-218-2247
Mailing address:
  • Phone: 480-218-7590
  • Fax: 480-218-2247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number7751
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2619
License Number StateAZ

VIII. Authorized Official

Name: MRS. PENNY SUE MCKINNEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 480-218-7590