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General NPI Number Information
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NPI Number | 1730809591
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Entity Type | Individual
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Provider Name | PHILLIP LARECE
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Gender | Male
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Dates
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Enumeration Date | 08/31/2022
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Last Update Date | 09/01/2022
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Provider Practice Location Address
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Address Line | 1700 E ELLIOT RD STE 8
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City | TEMPE
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State | AZ
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Zip | 85284-1631
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Country | US
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Telephone | 480-674-6060
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Fax |
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Provider Business Mailing Address
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Address Line | 1700 E ELLIOT RD STE 8
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City | TEMPE
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State | AZ
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Zip | 85284-1631
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D011396
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License Number State | AZ
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