Healthcare Provider Details

I. General information

NPI: 1710481098
Provider Name (Legal Business Name): BILTMORE PERIODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E MISSOURI AVE STE 102
PHOENIX AZ
85014-2916
US

IV. Provider business mailing address

6755 E. SUPERSTITION SPRINGS BLVD STE. 102
MESA AZ
85206
US

V. Phone/Fax

Practice location:
  • Phone: 480-218-7590
  • Fax: 480-218-2247
Mailing address:
  • Phone: 480-218-7590
  • Fax: 480-218-2247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7751
License Number StateAZ

VIII. Authorized Official

Name: PENNY SUE MCKINNEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 480-218-7590