MEDICARE: DESERT LILY DENTAL

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750974382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT LILY DENTAL

Provider Business Mailing Address
First Line	:	12020 N 35TH AVE STE 2
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-3213
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12020 N 35TH AVE STE 2
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-3213
Country	:	US
Telephone Number	:	435-637-2100
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TIFFANY BRAY
Credential	:
Telephone Number	:	435-637-2100

Provider Enumeration Date	:	02/15/2021
Last Update Date	:	02/15/2021

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Directions to “DESERT LILY DENTAL ” Practice Location

Language	Start Address	Practice Location

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