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General NPI Number Information
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NPI Number | 1295850808
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Entity Type | Organization
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Legal Business Name | PHOENIX MOUNTAIN DENTISTRY, LLC
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4155 N 108TH AVE STE 101
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City | PHOENIX
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State | AZ
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Zip | 85037-5464
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Country | US
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Telephone | 623-877-4044
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Fax | 623-877-0058
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Provider Business Mailing Address
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Address Line | 2323 W MESCAL ST STE 205
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City | PHOENIX
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State | AZ
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Zip | 85029-4764
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Country | US
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Telephone | 602-944-0073
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Fax | 602-944-0371
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Authorized Official
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Title or Position | AR AND INSURANCE MANAGER
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Name | MS. FAWNE PRYOR
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Credential |
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Telephone | 602-944-0073
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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 | D5983
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License Number State | AZ
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