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General NPI Number Information
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NPI Number | 1508218132
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Entity Type | Organization
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Legal Business Name | PHOENIX CHILDRENS DENTISTRY
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Dates
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Enumeration Date | 07/07/2016
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Last Update Date | 07/07/2016
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Provider Practice Location Address
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Address Line | 3575 W DEER VALLEY RD STE 110
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City | GLENDALE
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State | AZ
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Zip | 85308-2002
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Country | US
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Telephone | 339-237-0363
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Fax |
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Provider Business Mailing Address
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Address Line | 3575 W DEER VALLEY RD STE 110
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City | GLENDALE
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State | AZ
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Zip | 85308-2002
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Country | US
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Telephone | 339-237-0363
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MUKUL DAVE
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Credential | D.M.D
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Telephone | 339-237-0363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D008401
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License Number State | AZ
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