Healthcare Provider Details

I. General information

NPI: 1730490228
Provider Name (Legal Business Name): NORTH GROVES DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 N GILBERT RD STE 123
MESA AZ
85203
US

IV. Provider business mailing address

2158 N GILBERT RD STE 123
MESA AZ
85203
US

V. Phone/Fax

Practice location:
  • Phone: 480-649-7200
  • Fax:
Mailing address:
  • Phone: 480-649-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7286
License Number StateAZ

VIII. Authorized Official

Name: JASON KOLE PERKINS
Title or Position: OWNER
Credential: D.D.S.
Phone: 480-649-7200