MEDICARE: BRENT D. PULLEY DMD, LTD

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1619073699	OTHER		NPI INDIVIDUAL
2	1922488113	OTHER		ASSOCIATE'S NPI

General Provider Information

NPI Number	:	1356811772
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENT D. PULLEY DMD, LTD

Provider Business Mailing Address
First Line	:	1442 E CHANDLER BLVD STE 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-6265
Country	:	US
Telephone Number	:	480-460-1911
Fax Number	:

Provider Business Practice Location Address
First Line	:	1442 E CHANDLER BLVD STE 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-6265
Country	:	US
Telephone Number	:	480-460-1911
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. RONALD M FLORES
Credential	:	BS
Telephone Number	:	602-743-3650

Provider Enumeration Date	:	11/28/2018
Last Update Date	:	11/28/2018

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