Healthcare Provider Details

I. General information

NPI: 1558567743
Provider Name (Legal Business Name): PERCY B. TWINE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W BASELINE RD STE 172
PHOENIX AZ
85041-6573
US

IV. Provider business mailing address

2020 W BASELINE RD STE 172
PHOENIX AZ
85041-6573
US

V. Phone/Fax

Practice location:
  • Phone: 602-276-3010
  • Fax: 602-276-3013
Mailing address:
  • Phone: 602-276-3010
  • Fax: 480-998-9289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7259
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: