Healthcare Provider Details

I. General information

NPI: 1518563139
Provider Name (Legal Business Name): BLG DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6761 E TANQUE VERDE RD STE 3
TUCSON AZ
85715-5323
US

IV. Provider business mailing address

6761 E TANQUE VERDE RD STE 3
TUCSON AZ
85715-5323
US

V. Phone/Fax

Practice location:
  • Phone: 520-886-8106
  • Fax: 520-886-8510
Mailing address:
  • Phone: 520-886-8106
  • Fax: 520-886-8510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BENJAMIN L GARDEA JR.
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 520-886-8106