Healthcare Provider Details

I. General information

NPI: 1679016414
Provider Name (Legal Business Name): MORRIS ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213C US HIGHWAY 491
GALLUP NM
87301-4820
US

IV. Provider business mailing address

1910 E WILLOW TREE CT
GILBERT AZ
85234-4932
US

V. Phone/Fax

Practice location:
  • Phone: 505-979-5600
  • Fax:
Mailing address:
  • Phone: 480-452-5134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD3609
License Number StateNM

VIII. Authorized Official

Name: JOHN MELVIN MORRIS
Title or Position: OWNER
Credential: DDS
Phone: 480-452-5134