MEDICARE: EICON DENTAL, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1184825267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EICON DENTAL, LLC

Provider Business Mailing Address
First Line	:	2210 S MILL AVE
Second Line	:	SUITE 2
City	:	TEMPE
State	:	AZ
Zip	:	85282-2153
Country	:	US
Telephone Number	:	480-921-2434
Fax Number	:	480-921-2624

Provider Business Practice Location Address
First Line	:	2210 S MILL AVE
Second Line	:	SUITE 2
City	:	TEMPE
State	:	AZ
Zip	:	85282-2153
Country	:	US
Telephone Number	:	480-921-2434
Fax Number	:	480-921-2624

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MARK C EICH
Credential	:
Telephone Number	:	480-921-2434

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	10/21/2016

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