Healthcare Provider Details

I. General information

NPI: 1740468990
Provider Name (Legal Business Name): NBA DENTAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 N 24TH ST B-2
PHOENIX AZ
85016-6283
US

IV. Provider business mailing address

4102 N 24TH ST B-2
PHOENIX AZ
85016-6283
US

V. Phone/Fax

Practice location:
  • Phone: 602-956-2024
  • Fax: 602-956-2209
Mailing address:
  • Phone: 602-956-2024
  • Fax: 602-956-2209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5981
License Number StateAZ

VIII. Authorized Official

Name: FAWNE E PRYOR
Title or Position: INS MGR
Credential:
Phone: 623-536-2040