Healthcare Provider Details

I. General information

NPI: 1538284971
Provider Name (Legal Business Name): 75TH AVENUE DENTISTRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7545 W. BELL RD SUITE 105
PEORIA AZ
85382-4764
US

IV. Provider business mailing address

23525 N. 67TH AVE
GLENDALE AZ
85310
US

V. Phone/Fax

Practice location:
  • Phone: 623-412-2461
  • Fax: 623-979-7364
Mailing address:
  • Phone: 623-225-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5988
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD6772
License Number StateAZ

VIII. Authorized Official

Name: TAROLL ANN GRAZIANO
Title or Position: MANAGER
Credential:
Phone: 623-225-6555