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General NPI Number Information
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NPI Number | 1225409014
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Entity Type | Organization
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Legal Business Name | FAMILY DENTAL AT MOON VALLEY
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Dates
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Enumeration Date | 10/19/2015
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Last Update Date | 10/19/2015
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Provider Practice Location Address
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Address Line | 15640 N 7TH ST STE A4
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City | PHOENIX
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State | AZ
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Zip | 85022-3520
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Country | US
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Telephone | 602-843-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 15640 N 7TH ST STE A4
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City | PHOENIX
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State | AZ
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Zip | 85022-3520
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Country | US
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Telephone | 602-843-6000
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Fax |
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Authorized Official
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Title or Position | DENTIST, OWNER
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Name | CHAD HINES
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Credential | DDS
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Telephone | 319-331-3709
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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 | 9188
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License Number State | AZ
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