Healthcare Provider Details

I. General information

NPI: 1457719114
Provider Name (Legal Business Name): MOUNTAIN PARK DENTISTRY L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
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: 480-759-2130
Mailing address:
  • Phone: 480-759-9300
  • Fax: 480-759-2130

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 Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDY MOW
Title or Position: OWNER
Credential: D.D.S.
Phone: 480-759-9300