Healthcare Provider Details

I. General information

NPI: 1518068733
Provider Name (Legal Business Name): ADAM EDWARD GABRIELLA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500N HWY 89 NORTHERN ARIZONA HEALTH CARE SYSTEM
PRESCOTT AZ
86313
US

IV. Provider business mailing address

602 LA CORTA LANE
PRESCOTT AZ
86301
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-4860
  • Fax:
Mailing address:
  • Phone: 928-445-8488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD1466
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: