MEDICARE: DENTISTS OF PHOENIX, LLP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	122300000X	Dentist
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
3	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1134694698
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTS OF PHOENIX, LLP

Provider Business Mailing Address
First Line	:	1934 E CAMELBACK RD STE 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4126
Country	:	US
Telephone Number	:	602-903-4894
Fax Number	:	602-675-9843

Provider Business Practice Location Address
First Line	:	1934 E CAMELBACK RD STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4126
Country	:	US
Telephone Number	:	602-903-4894
Fax Number	:	602-675-9843

Authorized Official
Title or Position	:	CHIEF LEGAL OFFICER
Name	:	BEN J HIMMELSTEIN
Credential	:
Telephone Number	:	602-903-4849

Provider Enumeration Date	:	10/10/2018
Last Update Date	:	03/08/2022

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