Healthcare Provider Details

I. General information

NPI: 1457900656
Provider Name (Legal Business Name): EAST VALLEY IMPLANT AND PERIODONTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/10/2019
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

8952 E DESERT COVE AVE # D101
SCOTTSDALE AZ
85260-6775
US

V. Phone/Fax

Practice location:
  • Phone: 480-376-2848
  • Fax:
Mailing address:
  • Phone: 480-376-2848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MIKE COLE
Title or Position: VP INSURANCE PLAN MANAGEMENT
Credential:
Phone: 941-955-3150