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General NPI Number Information
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NPI Number | 1396772950
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Entity Type | Organization
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Legal Business Name | FLETCHER HEIGHTS DENTAL CARE PC
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Dates
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Enumeration Date | 06/27/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8272 W. LAKE PLEASANT PKWY., #204
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City | PEORIA
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State | AZ
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Zip | 85382-7432
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Country | US
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Telephone | 623-825-7833
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Fax | 623-362-9141
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Provider Business Mailing Address
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Address Line | 8272 W. LAKE PLEASANT PKWY., #204
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City | PEORIA
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State | AZ
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Zip | 85382-7432
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Country | US
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Telephone | 623-825-7833
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Fax | 623-362-9141
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MICHAEL A PROST
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Credential | D.D.S.
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Telephone | 623-825-7833
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12010098A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4974
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License Number State | AZ
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