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NPI Code Detail

MEDICARE: COUNTRY CLUB DENTAL MANAGEMENT CO, PC

MEDICARE: COUNTRY CLUB DENTAL MANAGEMENT CO, PC
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
11223G0001XGeneral Practice DentistryD07819AZ
2122300000XDentistD07819AZ

General Provider Information

NPI Number : 1164722021
Entity Type Code : Organization
Provider Name (Legal Business Name) : COUNTRY CLUB DENTAL MANAGEMENT CO, PC
Provider Business Mailing Address
First Line : 4704 E SOUTHERN AVE
Second Line :
City : MESA
State : AZ
Zip : 85206-2737
Country : US
Telephone Number : 480-889-9457
Fax Number : 480-889-9493
Provider Business Practice Location Address
First Line : 4704 E SOUTHERN AVE
Second Line : SUITE #1
City : MESA
State : AZ
Zip : 85206-2737
Country : US
Telephone Number : 480-889-9457
Fax Number : 480-889-9493
Authorized Official
Title or Position : DIRECTOR
Name : DR. LAWRENCE GEORGE GROOP
Credential : DMD
Telephone Number : 480-889-9457
Provider Enumeration Date : 10/26/2010
Last Update Date : 10/31/2013

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Directions to “COUNTRY CLUB DENTAL MANAGEMENT CO, PC ” Practice Location

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