Healthcare Provider Details

I. General information

NPI: 1467485599
Provider Name (Legal Business Name): VISHTASB BROUMAND DMD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5452
US

IV. Provider business mailing address

20950 N TATUM BLVD STE 200
PHOENIX AZ
85050-4269
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-8000
  • Fax:
Mailing address:
  • Phone: 480-284-8087
  • Fax: 480-659-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD008845
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN14533
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD008845
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: