Healthcare Provider Details

I. General information

NPI: 1043388010
Provider Name (Legal Business Name): RANDY L MOW DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15215 S 48TH ST STE 175
PHOENIX AZ
85044-9140
US

IV. Provider business mailing address

15215 S 48TH ST STE 175
PHOENIX AZ
85044-9140
US

V. Phone/Fax

Practice location:
  • Phone: 480-759-9300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD04156
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4156
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: