MEDICARE: MEGUMI MANAGEMENT LLC

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

General Provider Information

NPI Number	:	1396003448
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEGUMI MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	8639 W UNION HILLS DR
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-7000
Country	:	US
Telephone Number	:	623-876-1777
Fax Number	:	623-974-4974

Provider Business Practice Location Address
First Line	:	8639 W UNION HILLS DR
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-7000
Country	:	US
Telephone Number	:	623-876-1777
Fax Number	:	623-974-4974

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. KIM MACK
Credential	:	RDH, MBA
Telephone Number	:	480-231-7020

Provider Enumeration Date	:	04/26/2012
Last Update Date	:	04/26/2012

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