Healthcare Provider Details

I. General information

NPI: 1346873890
Provider Name (Legal Business Name): AZ DENTAL IMPLANT CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7102 E ACOMA DR
SCOTTSDALE AZ
85254-2771
US

IV. Provider business mailing address

7601 E INDIAN BEND RD APT 1050
SCOTTSDALE AZ
85250-4689
US

V. Phone/Fax

Practice location:
  • Phone: 602-386-8972
  • Fax:
Mailing address:
  • Phone: 602-386-8972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: SKY MOORE
Title or Position: MEMBER
Credential:
Phone: 602-386-8972