Healthcare Provider Details

I. General information

NPI: 1427384916
Provider Name (Legal Business Name): ENKATSU MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8279 W LAKE PLEASANT PKWY SUITE 110
PEORIA AZ
85382-7434
US

IV. Provider business mailing address

8279 W LAKE PLEASANT PKWY SUITE 110
PEORIA AZ
85382-7434
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-0120
  • Fax: 623-825-6820
Mailing address:
  • Phone: 623-878-0120
  • Fax: 623-825-6820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. KIMBERLY A. MACK
Title or Position: OWNER
Credential: R.D.H.
Phone: 480-231-7020