Healthcare Provider Details

I. General information

NPI: 1104257963
Provider Name (Legal Business Name): CENTRAL AVENUE SPECIALTY, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5133 N CENTRAL AVE SUITE 200
PHOENIX AZ
85012-1438
US

IV. Provider business mailing address

5133 N CENTRAL AVE SUITE 102
PHOENIX AZ
85012-1438
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-1776
  • Fax: 602-234-1814
Mailing address:
  • Phone: 602-266-1776
  • Fax: 602-234-1814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD008106
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD008035
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD07259
License Number StateAZ

VIII. Authorized Official

Name: DR. ANTHONY E HERRO
Title or Position: OWNER
Credential: DDS
Phone: 602-266-1776