=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760106967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZGAN DENTAL MANAGEMENT COMPANY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2022
-----------------------------------------------------
Last Update Date | 09/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1465 NW SAINT LUCIE WEST BLVD
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-1968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-348-4403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1465 NW SAINT LUCIE WEST BLVD
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-1968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-348-4403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING DIRECTOR
-----------------------------------------------------
Name | SUZEL GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-812-4903
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------