Healthcare Provider Details

I. General information

NPI: 1437222809
Provider Name (Legal Business Name): AZ PERIO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 01/27/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 E SHEA BLVD STE 110
SCOTTSDALE AZ
85260-6411
US

IV. Provider business mailing address

7425 E SHEA BLVD STE 110
SCOTTSDALE AZ
85260-6411
US

V. Phone/Fax

Practice location:
  • Phone: 480-991-0090
  • Fax: 480-951-2278
Mailing address:
  • Phone: 480-991-0090
  • Fax: 480-951-2278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2104
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5031
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6988
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5633
License Number StateAZ

VIII. Authorized Official

Name: DR. STEVEN GORDON REITAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 480-991-0090