Healthcare Provider Details

I. General information

NPI: 1326481995
Provider Name (Legal Business Name): GRAYSON JOHN BURGARDT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13260 N 94TH DR STE 410
PEORIA AZ
85381-4241
US

IV. Provider business mailing address

6519 E BLUEFIELD AVE
PHOENIX AZ
85054-6741
US

V. Phone/Fax

Practice location:
  • Phone: 620-260-5655
  • Fax:
Mailing address:
  • Phone: 620-260-5655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number28733
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD010692
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: