Healthcare Provider Details

I. General information

NPI: 1194247098
Provider Name (Legal Business Name): SCOTTSDALE PROSTHODONTISTS II, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 N SCOTTSDALE RD STE 220
SCOTTSDALE AZ
85254-6732
US

IV. Provider business mailing address

11111 N SCOTTSDALE RD STE 220
SCOTTSDALE AZ
85254-6732
US

V. Phone/Fax

Practice location:
  • Phone: 480-368-0060
  • Fax:
Mailing address:
  • Phone: 480-368-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2139
License Number StateAZ

VIII. Authorized Official

Name: DR. MICHAEL GIBBONS
Title or Position: PROSTHODONTIST
Credential: DMD
Phone: 480-368-0060