MEDICARE: METROCENTER AZ DENTAL 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1033685268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METROCENTER AZ DENTAL PLLC

Provider Business Mailing Address
First Line	:	PO BOX 3189
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13220-3189
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2827 W PEORIA AVE STE 101
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-5213
Country	:	US
Telephone Number	:	602-749-1000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID SUNG
Credential	:
Telephone Number	:	602-749-1000

Provider Enumeration Date	:	10/15/2018
Last Update Date	:	10/15/2018

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