Healthcare Provider Details

I. General information

NPI: 1992679534
Provider Name (Legal Business Name): CARLOS JAVIER VALENCIA RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 W MAIN ST
MESA AZ
85201-6920
US

IV. Provider business mailing address

3033 N CENTRAL AVE STE 145
PHOENIX AZ
85012-2808
US

V. Phone/Fax

Practice location:
  • Phone: 480-964-2273
  • Fax:
Mailing address:
  • Phone: 623-583-3001
  • Fax: 623-974-6721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number4877
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: