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General NPI Number Information
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NPI Number | 1972916690
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Entity Type | Organization
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Legal Business Name | PHOENIX DENTAL GROUP LLC
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Dates
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Enumeration Date | 06/10/2014
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Last Update Date | 06/10/2014
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Provider Practice Location Address
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Address Line | 5115 N DYSART RD SUITE 202-142
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City | LITCHFIELD PARK
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State | AZ
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Zip | 85340-3032
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Country | US
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Telephone | 602-232-1980
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Fax |
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Provider Business Mailing Address
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Address Line | 1423 N 16TH ST
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City | PHOENIX
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State | AZ
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Zip | 85006-3004
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Country | US
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Telephone | 602-232-1980
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Fax |
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Authorized Official
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Title or Position | MEMBER/OWNER
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Name | DR. MICHAEL WASSEF
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Credential | D.D.S.
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Telephone | 602-232-1980
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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