Healthcare Provider Details

I. General information

NPI: 1891875498
Provider Name (Legal Business Name): PHOENIX PEDIATRIC DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6750 N 19TH AVE
PHOENIX AZ
85015-1127
US

IV. Provider business mailing address

6750 N 19TH AVE
PHOENIX AZ
85015-1127
US

V. Phone/Fax

Practice location:
  • Phone: 602-242-5741
  • Fax: 602-242-5742
Mailing address:
  • Phone: 602-242-5741
  • Fax: 602-242-5742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateAZ

VIII. Authorized Official

Name: LUZ PACHECO
Title or Position: BUSINESS MANAGER
Credential:
Phone: 602-242-5741