Healthcare Provider Details

I. General information

NPI: 1194745026
Provider Name (Legal Business Name): AZIZ ALI BOHRA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13360 N 94TH DR SUITE C
PEORIA AZ
85381-4837
US

IV. Provider business mailing address

13360 N 94TH DR SUITE C
PEORIA AZ
85381-4837
US

V. Phone/Fax

Practice location:
  • Phone: 623-933-1989
  • Fax: 623-583-2635
Mailing address:
  • Phone: 623-933-1989
  • Fax: 623-583-2635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD5585
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: