Healthcare Provider Details

I. General information

NPI: 1023186087
Provider Name (Legal Business Name): OREST G KOMARNYCKYJ DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E MISSOURI AVE SUITE 208
PHOENIX AZ
85014-2915
US

IV. Provider business mailing address

1277 E MISSOURI AVE SUITE 208
PHOENIX AZ
85014-2915
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-3430
  • Fax:
Mailing address:
  • Phone: 602-266-3430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD2707
License Number StateAZ

VIII. Authorized Official

Name: DR. OREST GREGORY KOMARNYCKYJ
Title or Position: PRESIDENT PERIODONTIST
Credential: DDS
Phone: 602-266-3430