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General NPI Number Information
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NPI Number | 1073960928
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Entity Type | Organization
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Legal Business Name | WESTGATE PERIODONTICS, PLLC
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Dates
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Enumeration Date | 05/20/2016
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Last Update Date | 05/20/2016
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Provider Practice Location Address
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Address Line | 6535 W CAMELBACK RD SUITE #1
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City | PHOENIX
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State | AZ
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Zip | 85033-1608
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Country | US
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Telephone | 623-848-1901
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Fax | 623-848-8778
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Provider Business Mailing Address
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Address Line | 6535 W CAMELBACK RD SUITE #1
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City | PHOENIX
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State | AZ
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Zip | 85033-1608
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Country | US
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Telephone | 623-848-1901
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Fax | 623-848-8778
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | KURT D WALLIN
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Credential | D.M.D.
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Telephone | 623-848-1901
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | D008400
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License Number State | AZ
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