MEDICARE: JOSHO MANAGEMENT

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	D4234	AZ

General Provider Information

NPI Number	:	1114305158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSHO MANAGEMENT

Provider Business Mailing Address
First Line	:	4505 E CHANDLER BLVD
Second Line	:	SUITE 150
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7684
Country	:	US
Telephone Number	:	480-753-3692
Fax Number	:

Provider Business Practice Location Address
First Line	:	4505 E CHANDLER BLVD
Second Line	:	SUITE 150
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7684
Country	:	US
Telephone Number	:	480-753-3692
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ MANAGING DIRECTOR
Name	:	KIM MACK
Credential	:
Telephone Number	:	480-231-7020

Provider Enumeration Date	:	05/11/2015
Last Update Date	:	05/11/2015

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