Healthcare Provider Details

I. General information

NPI: 1962689489
Provider Name (Legal Business Name): DAN BANGART PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 03/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13660 N 94TH DRIVE SUITE F-1
PEORIA AZ
85381-4323
US

IV. Provider business mailing address

13660 N 94TH DRIVE SUITE F-1
PEORIA AZ
85381-4323
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-0522
  • Fax:
Mailing address:
  • Phone: 623-974-0522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0345
License Number StateAZ

VIII. Authorized Official

Name: DAN BANGART
Title or Position: PRESIDENT
Credential:
Phone: 623-974-0522