Healthcare Provider Details

I. General information

NPI: 1871018887
Provider Name (Legal Business Name): SUMMIT DENTAL SPECIALTY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15810 S 45TH ST STE 120
PHOENIX AZ
85048-7695
US

IV. Provider business mailing address

15810 S 45TH ST STE 120
PHOENIX AZ
85048-7695
US

V. Phone/Fax

Practice location:
  • Phone: 480-893-3636
  • Fax: 480-893-3635
Mailing address:
  • Phone: 480-893-3636
  • Fax: 480-893-3635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberD06147
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD9064
License Number StateAZ

VIII. Authorized Official

Name: SHIELA DOMINGUEZ
Title or Position: MANAGING MEMBER
Credential:
Phone: 480-669-6419