MEDICARE: GREENWAY 40 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	AZ4044	AZ
2	122300000X	Dentist	AZ3740	AZ

General Provider Information

NPI Number	:	1174810840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENWAY 40 LLC

Provider Business Mailing Address
First Line	:	4022 E GREENWAY RD
Second Line	:	STE 13
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4799
Country	:	US
Telephone Number	:	602-595-1115
Fax Number	:

Provider Business Practice Location Address
First Line	:	4022 E GREENWAY RD
Second Line	:	STE 13
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4797
Country	:	US
Telephone Number	:	602-595-1115
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. DAVID J VELASCO JR.
Credential	:	DDS
Telephone Number	:	602-595-1115

Provider Enumeration Date	:	07/01/2011
Last Update Date	:	08/02/2012

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Directions to “GREENWAY 40 LLC ” Practice Location

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