Healthcare Provider Details

I. General information

NPI: 1770015992
Provider Name (Legal Business Name): HORIZON DENTAL GROUP NEW RIVER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46641 N BLACK CANYON HWY STE 7
NEW RIVER AZ
85087-6941
US

IV. Provider business mailing address

46641 N BLACK CANYON HWY STE 7
NEW RIVER AZ
85087-6941
US

V. Phone/Fax

Practice location:
  • Phone: 623-742-7220
  • Fax: 928-458-7090
Mailing address:
  • Phone: 623-742-7220
  • Fax: 928-458-7090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD008994
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5634
License Number StateAZ

VIII. Authorized Official

Name: DR. MARK COSTES
Title or Position: OWNER/ DENTIST
Credential: DDS
Phone: 928-636-1565