MEDICARE: ICON DENTAL 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	1223G0001X	General Practice Dentistry	D05930	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1235163270	OTHER	AZ	TYPE 1 NPI

General Provider Information

NPI Number	:	1245740182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICON DENTAL PLLC

Provider Business Mailing Address
First Line	:	7435 W LOWER BUCKEYE RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85043-7636
Country	:	US
Telephone Number	:	623-432-0700
Fax Number	:	866-892-0774

Provider Business Practice Location Address
First Line	:	7435 W LOWER BUCKEYE RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85043-7636
Country	:	US
Telephone Number	:	623-432-0700
Fax Number	:	866-892-0774

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROBERT Z BADALOV
Credential	:	DDS
Telephone Number	:	623-432-0700

Provider Enumeration Date	:	10/05/2017
Last Update Date	:	10/05/2017

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Directions to “ICON DENTAL PLLC ” Practice Location

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