Healthcare Provider Details

I. General information

NPI: 1255946257
Provider Name (Legal Business Name): TATUM POINT DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 08/30/2024
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 E BELL RD STE #15
PHOENIX AZ
85032-2301
US

IV. Provider business mailing address

TATUM POINT DENTISTRY LLC 19601 N BLACK CANYON HWY, #201
PHOENIX AZ
85027-4107
US

V. Phone/Fax

Practice location:
  • Phone: 623-289-2580
  • Fax:
Mailing address:
  • Phone: 623-289-2580
  • Fax: 623-289-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA KELLICI
Title or Position: MANAGER
Credential:
Phone: 623-439-2280