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General NPI Number Information
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NPI Number | 1215610555
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Entity Type | Organization
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Legal Business Name | MOON VALLEY DENTAL LLC
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Dates
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Enumeration Date | 08/14/2023
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Last Update Date | 08/14/2023
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Provider Practice Location Address
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Address Line | 13825 N 7TH ST STE C
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City | PHOENIX
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State | AZ
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Zip | 85022-4342
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Country | US
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Telephone | 602-993-9912
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Fax |
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Provider Business Mailing Address
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Address Line | 8035 S 27TH WAY
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City | PHOENIX
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State | AZ
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Zip | 85042-7063
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Country | US
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Telephone | 480-760-5528
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MARK C EICH
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Credential |
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Telephone | 480-310-2582
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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