Healthcare Provider Details

I. General information

NPI: 1588733588
Provider Name (Legal Business Name): RADOSTIN ILIEV MLADENOV RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15182 N 75TH AVE SUITE 120
PEORIA AZ
85381-4722
US

IV. Provider business mailing address

14195 W AMELIA AVE
GOODYEAR AZ
85338-8447
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2400
  • Fax: 623-878-3151
Mailing address:
  • Phone: 623-535-8438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberH6000
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: