MEDICARE: DESERT VISTA DENTAL WEST PLLC

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	:	1548307424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT VISTA DENTAL WEST PLLC

Provider Business Mailing Address
First Line	:	1646 N LITCHFIELD RD
Second Line	:	SUITE 125
City	:	GOODYEAR
State	:	AZ
Zip	:	85395-1203
Country	:	US
Telephone Number	:	623-935-2755
Fax Number	:	623-935-0265

Provider Business Practice Location Address
First Line	:	1646 N LITCHFIELD RD
Second Line	:	SUITE 125
City	:	GOODYEAR
State	:	AZ
Zip	:	85395-1203
Country	:	US
Telephone Number	:	623-935-2755
Fax Number	:	623-935-0265

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. STACY K CORDOVA
Credential	:
Telephone Number	:	623-935-2755

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	10/15/2015

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