Healthcare Provider Details

I. General information

NPI: 1962818633
Provider Name (Legal Business Name): CODY HESLINGTON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21755 N 77TH AVE STE 1210
PEORIA AZ
85382-2112
US

IV. Provider business mailing address

21755 N 77TH AVE STE 1210
PEORIA AZ
85382-2112
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-0899
  • Fax: 623-248-9951
Mailing address:
  • Phone: 623-248-0899
  • Fax: 623-248-9951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number9608
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number30407
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD009608
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: