Healthcare Provider Details

I. General information

NPI: 1093266363
Provider Name (Legal Business Name): PALMER FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 W 8TH ST
SAFFORD AZ
85546
US

IV. Provider business mailing address

810 W 8TH ST
SAFFORD AZ
85546-3109
US

V. Phone/Fax

Practice location:
  • Phone: 928-428-6161
  • Fax:
Mailing address:
  • Phone: 928-428-6161
  • Fax: 928-428-6169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8425
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8425
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8425
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number8425
License Number StateAZ

VIII. Authorized Official

Name: DR. MARK PALMER
Title or Position: OWNER
Credential:
Phone: 928-428-6161