MEDICARE: SOUTHERN DENTAL

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	5995	AZ

General Provider Information

NPI Number	:	1265616213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN DENTAL

Provider Business Mailing Address
First Line	:	3320 W. SOUTHERN AVENUE
Second Line	:	SUITE # 108
City	:	PHOENIX
State	:	AZ
Zip	:	85041
Country	:	US
Telephone Number	:	602-305-8800
Fax Number	:	602-305-8801

Provider Business Practice Location Address
First Line	:	3320 W. SOUTHERN AVENUE
Second Line	:	SUITE # 108
City	:	PHOENIX
State	:	AZ
Zip	:	85041
Country	:	US
Telephone Number	:	602-305-8800
Fax Number	:	602-305-8801

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. PETER P NGUYEN
Credential	:	DMD
Telephone Number	:	602-305-8800

Provider Enumeration Date	:	12/27/2007
Last Update Date	:	12/27/2007

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Directions to “SOUTHERN DENTAL ” Practice Location

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