MEDICARE: GENERAL DENTISTRY 4 KIDS-GLENDALE 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	4964	AZ

General Provider Information

NPI Number	:	1770927410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENERAL DENTISTRY 4 KIDS-GLENDALE PLLC

Provider Business Mailing Address
First Line	:	3554 W GLENDALE AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-8358
Country	:	US
Telephone Number	:	602-888-7844
Fax Number	:	602-841-0426

Provider Business Practice Location Address
First Line	:	3554 W GLENDALE AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-8358
Country	:	US
Telephone Number	:	602-888-7844
Fax Number	:	602-841-0426

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	BRAD ROBERTS
Credential	:	DMD
Telephone Number	:	602-888-7844

Provider Enumeration Date	:	04/24/2013
Last Update Date	:	02/19/2016

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