=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437611803
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MDBB MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2019
-----------------------------------------------------
Last Update Date | 02/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2680 S VAL VISTA DR STE 101
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-522-5599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2680 S VAL VISTA DR STE 101
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | BART PALMISANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 723-752-2559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------