MEDICARE: KIDZ CONNEXTION DENTAL CENTER

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	D5376	AZ

General Provider Information

NPI Number	:	1295037687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDZ CONNEXTION DENTAL CENTER

Provider Business Mailing Address
First Line	:	4727 E BELL RD
Second Line	:	SUITE # 45101
City	:	PHOENIX
State	:	AZ
Zip	:	85032-2308
Country	:	US
Telephone Number	:	623-223-1001
Fax Number	:	623-873-7440

Provider Business Practice Location Address
First Line	:	2533 N 75TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85035-1211
Country	:	US
Telephone Number	:	623-223-1001
Fax Number	:	623-873-7440

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. JOHN GRANETO
Credential	:	D.M.D.
Telephone Number	:	623-223-1001

Provider Enumeration Date	:	11/17/2010
Last Update Date	:	02/06/2014

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