Healthcare Provider Details

I. General information

NPI: 1356885073
Provider Name (Legal Business Name): BG DENTAL INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 E KNIGHT DR
TUCSON AZ
85712-2147
US

IV. Provider business mailing address

5255 E KNIGHT DR
TUCSON AZ
85712-2147
US

V. Phone/Fax

Practice location:
  • Phone: 520-881-6767
  • Fax: 520-881-6767
Mailing address:
  • Phone: 520-881-6767
  • Fax: 520-881-6767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number7359
License Number StateAZ

VIII. Authorized Official

Name: MR. BRIAN GLEN MITCHELL
Title or Position: DENTIST
Credential: D.D.S.
Phone: 520-881-6767