Healthcare Provider Details

I. General information

NPI: 1376019075
Provider Name (Legal Business Name): EAST VALLEY IMPLANT & PERIODONTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 E BASELINE RD STE 112
MESA AZ
85204-7287
US

IV. Provider business mailing address

3048 E BASELINE RD STE 112
MESA AZ
85204-7287
US

V. Phone/Fax

Practice location:
  • Phone: 480-558-4504
  • Fax: 480-827-9703
Mailing address:
  • Phone: 480-558-4504
  • Fax: 480-827-9703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: MRS. BRETT E LEE
Title or Position: OFFICE MANAGER
Credential:
Phone: 480-558-4504