Healthcare Provider Details

I. General information

NPI: 1952778532
Provider Name (Legal Business Name): SERGIO GOMES DE SOUZA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2015
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15416 N 99TH AVE
SUN CITY AZ
85351-1962
US

IV. Provider business mailing address

26818 N 65TH DR
PHOENIX AZ
85083-6506
US

V. Phone/Fax

Practice location:
  • Phone: 623-875-7917
  • Fax:
Mailing address:
  • Phone: 622-363-8715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009301
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: