Healthcare Provider Details

I. General information

NPI: 1790471704
Provider Name (Legal Business Name): NICHOLAS MARTIN BOCCHINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7449 E OSBORN RD STE 4
SCOTTSDALE AZ
85251-6448
US

IV. Provider business mailing address

6580 E MCDOWELL RD UNIT 3209
SCOTTSDALE AZ
85257-0039
US

V. Phone/Fax

Practice location:
  • Phone: 816-805-8140
  • Fax:
Mailing address:
  • Phone: 816-805-8140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012968
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number62086
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2023021473
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: