Healthcare Provider Details

I. General information

NPI: 1063969046
Provider Name (Legal Business Name): HORIZON DENTAL GROUP SPRING VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17301 E SPRING VALLEY RD STE C
SPRING VALLEY AZ
86333-4263
US

IV. Provider business mailing address

17301 E SPRING VALLEY RD STE C
SPRING VALLEY AZ
86333-4263
US

V. Phone/Fax

Practice location:
  • Phone: 928-632-9099
  • Fax: 928-458-7090
Mailing address:
  • Phone: 928-632-9099
  • Fax: 928-458-7090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5634
License Number StateAZ

VIII. Authorized Official

Name: DR. MARK ANTHONY COSTES
Title or Position: OWNER
Credential: DDS
Phone: 928-925-6522