MEDICARE: DENTISTRY FOR CHILDREN 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	1223P0221X	Pediatric Dentistry	5589	AZ
2	122300000X	Dentist	5678	AZ

General Provider Information

NPI Number	:	1154540367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTRY FOR CHILDREN PLLC

Provider Business Mailing Address
First Line	:	1245 E SOUTHERN AVE
Second Line	:	STE 12
City	:	MESA
State	:	AZ
Zip	:	85204-5137
Country	:	US
Telephone Number	:	480-610-6544
Fax Number	:	480-633-0670

Provider Business Practice Location Address
First Line	:	1245 E SOUTHERN AVE
Second Line	:	STE 12
City	:	MESA
State	:	AZ
Zip	:	85204-5137
Country	:	US
Telephone Number	:	480-610-6544
Fax Number	:	480-633-0670

Authorized Official
Title or Position	:	OFFICE SUPERVISOR
Name	:	SHARRON KEENE
Credential	:
Telephone Number	:	480-610-6544

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	09/11/2025

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