MEDICARE: TOOTH CASTLE PEDIATRIC DENTISTRY

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1316113715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOOTH CASTLE PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	PO BOX 45359
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85064-5359
Country	:	US
Telephone Number	:	602-841-4400
Fax Number	:	602-841-4404

Provider Business Practice Location Address
First Line	:	2316 W BETHANY HOME RD
Second Line	:	SUITE 110
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1850
Country	:	US
Telephone Number	:	602-841-4400
Fax Number	:	601-841-4404

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARIA ANGELES FUENTES
Credential	:	DDS
Telephone Number	:	602-841-4400

Provider Enumeration Date	:	05/06/2008
Last Update Date	:	08/21/2013

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Directions to “TOOTH CASTLE PEDIATRIC DENTISTRY ” Practice Location

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