=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679974232
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX DENTAL CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2014
-----------------------------------------------------
Last Update Date | 09/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 W INDIAN SCHOOL RD STE 6
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85015-5114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-650-1700
-----------------------------------------------------
Fax | 602-650-1704
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 W INDIAN SCHOOL RD STE 6
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85015-5114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-650-1700
-----------------------------------------------------
Fax | 602-650-1704
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | JASON H NORDEAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-650-1700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8657
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------