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General NPI Number Information
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NPI Number | 1174810840
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Entity Type | Organization
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Legal Business Name | GREENWAY 40 LLC
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Dates
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Enumeration Date | 07/01/2011
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Last Update Date | 08/02/2012
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Provider Practice Location Address
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Address Line | 4022 E GREENWAY RD STE 13
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City | PHOENIX
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State | AZ
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Zip | 85032-4797
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Country | US
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Telephone | 602-595-1115
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Fax |
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Provider Business Mailing Address
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Address Line | 4022 E GREENWAY RD STE 13
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City | PHOENIX
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State | AZ
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Zip | 85032-4799
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Country | US
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Telephone | 602-595-1115
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. DAVID J VELASCO JR.
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Credential | DDS
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Telephone | 602-595-1115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | AZ4044
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | AZ3740
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License Number State | AZ
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