Healthcare Provider Details

I. General information

NPI: 1972128858
Provider Name (Legal Business Name): BURGARDT AND DIAZ DENTAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13260 N 94TH DR STE 410
PEORIA AZ
85381-4241
US

IV. Provider business mailing address

6519 E BLUEFIELD AVE
PHOENIX AZ
85054-6741
US

V. Phone/Fax

Practice location:
  • Phone: 620-260-5655
  • Fax:
Mailing address:
  • Phone: 620-260-5655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. GRAYSON JOHN BURGARDT
Title or Position: MEMBER, MANAGER, AND EMPLOYEE
Credential: DDS, MSD
Phone: 620-260-5655