=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952832008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENICIAN DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2017
-----------------------------------------------------
Last Update Date | 03/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9160 N 43RD AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85302-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-931-9221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9233 E PINE VALLEY RD
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-228-0661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. POURYA SHAHNAZ
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 480-228-0661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D008519
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------