MEDICARE: SONORTICA DENT ALL GROUP, 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1598160038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SONORTICA DENT ALL GROUP, LLC

Provider Business Mailing Address
First Line	:	2043 EAST KRYSTAL ST
Second Line	:
City	:	SAN LUIS
State	:	AZ
Zip	:	85349-0426
Country	:	US
Telephone Number	:	928-550-4193
Fax Number	:

Provider Business Practice Location Address
First Line	:	2043 EAST KRYSTAL ST
Second Line	:
City	:	SAN LUIS
State	:	AZ
Zip	:	85349-0426
Country	:	US
Telephone Number	:	928-550-4193
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CARLOS SANCHEZ
Credential	:
Telephone Number	:	928-550-4193

Provider Enumeration Date	:	10/27/2014
Last Update Date	:	10/27/2014

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