Healthcare Provider Details

I. General information

NPI: 1992322192
Provider Name (Legal Business Name): MDBB MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 07/03/2020
Certification Date: 07/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1842 E BASELINE RD
TEMPE AZ
85283-1514
US

IV. Provider business mailing address

1842 E BASELINE RD
TEMPE AZ
85283-1514
US

V. Phone/Fax

Practice location:
  • Phone: 480-576-6323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BART PALMISANO
Title or Position: OFFICER
Credential:
Phone: 727-522-5599