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General NPI Number Information
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NPI Number | 1659848828
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Entity Type | Organization
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Legal Business Name | JG DENTAL PLLC
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Dates
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Enumeration Date | 10/25/2018
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Last Update Date | 10/25/2018
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Provider Practice Location Address
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Address Line | 4901 W BELL RD STE 140
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City | GLENDALE
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State | AZ
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Zip | 85308-3465
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Country | US
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Telephone | 623-738-4904
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Fax |
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Provider Business Mailing Address
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Address Line | 10111 N EL MIRAGE RD STE 4
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City | EL MIRAGE
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State | AZ
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Zip | 85335-3605
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Country | US
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Telephone | 623-738-4904
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Fax |
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Authorized Official
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Title or Position | OWNER MANAGER
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Name | DR. GRACE S PARK
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Credential | DDS
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Telephone | 623-738-4904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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