Healthcare Provider Details

I. General information

NPI: 1194189878
Provider Name (Legal Business Name): THANA DAWN BOYD DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THANA DAWN TACHEENE DENTAL HYGIENIST

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 N CENTRAL AVE BLDG. C
PHOENIX AZ
85012-3330
US

IV. Provider business mailing address

4041 N CENTRAL AVE BLDG. C
PHOENIX AZ
85012-3330
US

V. Phone/Fax

Practice location:
  • Phone: 602-279-5262
  • Fax: 602-263-0452
Mailing address:
  • Phone: 602-279-5262
  • Fax: 602-263-0452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH06758
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number00087
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: