Healthcare Provider Details

I. General information

NPI: 1760106967
Provider Name (Legal Business Name): AZGAN DENTAL MANAGEMENT COMPANY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 NW SAINT LUCIE WEST BLVD
PORT ST LUCIE FL
34986-1968
US

IV. Provider business mailing address

1465 NW SAINT LUCIE WEST BLVD
PORT ST LUCIE FL
34986-1968
US

V. Phone/Fax

Practice location:
  • Phone: 772-348-4403
  • Fax:
Mailing address:
  • Phone: 772-348-4403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: SUZEL GONZALEZ
Title or Position: BILLING DIRECTOR
Credential:
Phone: 772-812-4903