MEDICARE: UPTOWN PEDIATRIC DENTAL GROUP, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1003458688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPTOWN PEDIATRIC DENTAL GROUP, PLLC

Provider Business Mailing Address
First Line	:	7236 N 18TH PL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-5236
Country	:	US
Telephone Number	:	312-345-5526
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 E MISSOURI AVE STE 103
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2443
Country	:	US
Telephone Number	:	602-279-2981
Fax Number	:

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	ERNEST NEHRER
Credential	:	DDS
Telephone Number	:	831-234-5526

Provider Enumeration Date	:	10/15/2019
Last Update Date	:	10/15/2019

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