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General NPI Number Information
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NPI Number | 1497046395
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Entity Type | Organization
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Legal Business Name | AZ LIFE DENTISTRY, PLLC
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Dates
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Enumeration Date | 04/26/2011
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Last Update Date | 04/26/2011
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Provider Practice Location Address
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Address Line | 13065 W MCDOWELL RD BUILDING B, SUITE #112
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City | AVONDALE
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State | AZ
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Zip | 85392-6439
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Country | US
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Telephone | 623-455-3600
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Fax |
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Provider Business Mailing Address
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Address Line | 13065 W MCDOWELL RD BUILDING B, SUITE #112
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City | AVONDALE
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State | AZ
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Zip | 85392-6439
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Country | US
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Telephone | 623-455-3600
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. SHAHAB ARDALAN
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Credential | DDS
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Telephone | 480-861-5261
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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 |
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License Number State |
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