MEDICARE: CRESCENT VIEW FAMILY DENTAL, LLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1083938153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESCENT VIEW FAMILY DENTAL, LLC

Provider Business Mailing Address
First Line	:	4015 N 15TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-5209
Country	:	US
Telephone Number	:	602-248-0434
Fax Number	:	602-248-2814

Provider Business Practice Location Address
First Line	:	4015 N 15TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-5209
Country	:	US
Telephone Number	:	602-248-0434
Fax Number	:	602-248-2814

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	LARAINE GREY
Credential	:
Telephone Number	:	602-248-0434

Provider Enumeration Date	:	03/18/2010
Last Update Date	:	03/18/2010

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