MEDICARE: SOUTH CENTRAL DENTAL 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	1223G0001X	General Practice Dentistry	D7892	AZ

General Provider Information

NPI Number	:	1952636573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH CENTRAL DENTAL LLC

Provider Business Mailing Address
First Line	:	6831 S CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-5420
Country	:	US
Telephone Number	:	602-268-8881
Fax Number	:	602-243-9826

Provider Business Practice Location Address
First Line	:	6831 S CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-5420
Country	:	US
Telephone Number	:	602-268-8881
Fax Number	:	602-243-9826

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. JUSTIN CHURCH
Credential	:	DMD
Telephone Number	:	480-206-0139

Provider Enumeration Date	:	10/15/2009
Last Update Date	:	10/15/2009

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