=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629293477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PECK FAMILY DENTISTRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14640 N TATUM BLVD STE 10
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-867-1398
-----------------------------------------------------
Fax | 602-867-1702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14640 N TATUM BLVD STE 10
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-867-1398
-----------------------------------------------------
Fax | 602-867-1702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | KEVIN M PECK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 602-867-1398
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4163 & 4181
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------