MEDICARE: MOUNTAIN PARK DENTISTRY L.L.C.

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	1223P0300X	Periodontics
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1457719114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN PARK DENTISTRY L.L.C.

Provider Business Mailing Address
First Line	:	15215 S 48TH ST STE 175
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-9140
Country	:	US
Telephone Number	:	480-759-9300
Fax Number	:	480-759-2130

Provider Business Practice Location Address
First Line	:	15215 S 48TH ST STE 175
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-9140
Country	:	US
Telephone Number	:	480-759-9300
Fax Number	:	480-759-2130

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RANDY MOW
Credential	:	D.D.S.
Telephone Number	:	480-759-9300

Provider Enumeration Date	:	02/09/2016
Last Update Date	:	02/09/2016

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