Healthcare Provider Details

I. General information

NPI: 1588759161
Provider Name (Legal Business Name): KS AZ-1, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3554 W GLENDALE AVE
PHOENIX AZ
85051-8358
US

IV. Provider business mailing address

1090 NORTHCHASE PKWY SE STE 150
MARIETTA GA
30067-6407
US

V. Phone/Fax

Practice location:
  • Phone: 602-233-5665
  • Fax: 602-233-5666
Mailing address:
  • Phone: 770-916-5028
  • Fax: 678-247-7858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DALE MAYFIELD
Title or Position: PRESIDENT
Credential: DMD
Phone: 770-916-5028