MEDICARE: HORIZON DENTAL GROUP NEW RIVER

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	122300000X	Dentist	D008994	AZ
2	122300000X	Dentist	D5634	AZ

General Provider Information

NPI Number	:	1770015992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HORIZON DENTAL GROUP NEW RIVER

Provider Business Mailing Address
First Line	:	46641 N BLACK CANYON HWY STE 7
Second Line	:
City	:	NEW RIVER
State	:	AZ
Zip	:	85087-6941
Country	:	US
Telephone Number	:	623-742-7220
Fax Number	:	928-458-7090

Provider Business Practice Location Address
First Line	:	46641 N BLACK CANYON HWY STE 7
Second Line	:
City	:	NEW RIVER
State	:	AZ
Zip	:	85087-6941
Country	:	US
Telephone Number	:	623-742-7220
Fax Number	:	928-458-7090

Authorized Official
Title or Position	:	OWNER/ DENTIST
Name	:	DR. MARK COSTES
Credential	:	DDS
Telephone Number	:	928-636-1565

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	03/28/2017

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Directions to “HORIZON DENTAL GROUP NEW RIVER ” Practice Location

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