Healthcare Provider Details

I. General information

NPI: 1104374917
Provider Name (Legal Business Name): DYNAMIC DENTAL LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7170 E MCDONALD DR STE 12
SCOTTSDALE AZ
85253-5424
US

IV. Provider business mailing address

60 LORRAINE CT.
HOLBROOK NY
11741
US

V. Phone/Fax

Practice location:
  • Phone: 480-646-6004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MR. MARC A RESASCO
Title or Position: OWNER
Credential:
Phone: 480-646-6004