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General NPI Number Information
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NPI Number | 1972128858
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Entity Type | Organization
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Legal Business Name | BURGARDT AND DIAZ DENTAL GROUP, PLLC
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Dates
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Enumeration Date | 06/16/2020
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Last Update Date | 07/01/2020
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Provider Practice Location Address
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Address Line | 13260 N 94TH DR STE 410
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City | PEORIA
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State | AZ
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Zip | 85381-4241
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Country | US
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Telephone | 620-260-5655
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Fax |
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Provider Business Mailing Address
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Address Line | 6519 E BLUEFIELD AVE
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City | PHOENIX
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State | AZ
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Zip | 85054-6741
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Country | US
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Telephone | 620-260-5655
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Fax |
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Authorized Official
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Title or Position | MEMBER, MANAGER, AND EMPLOYEE
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Name | DR. GRAYSON JOHN BURGARDT
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Credential | DDS, MSD
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Telephone | 620-260-5655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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