Healthcare Provider Details

I. General information

NPI: 1306277918
Provider Name (Legal Business Name): HERMOSA DENTAL AND ORTHODONTICS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2013
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 W GLENDALE AVE 30
PHOENIX AZ
85051-8386
US

IV. Provider business mailing address

3415 W GLENDALE AVE 30
PHOENIX AZ
85051-8386
US

V. Phone/Fax

Practice location:
  • Phone: 602-242-0550
  • Fax: 602-242-4965
Mailing address:
  • Phone: 602-242-0550
  • Fax: 602-242-4965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD6876
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD8403
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD8369
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD5067
License Number StateAZ

VIII. Authorized Official

Name: MR. RASOUL SALIM
Title or Position: OWNER
Credential:
Phone: 602-242-0550