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Provider Information for 1053793893

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1053793893

Calendar   Last Updated:  2020-09-02
  Certification Date:  2020-09-02


Name Value
NPI 1053793893
Enumeration Date 2015-06-28
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 4314 E LONE CACTUS DR
PHOENIX, AZ 85050-6888
United States

Phone: 925-262-3069 | Fax:
View Map External Link
Primary Practice Address 4022 E GREENWAY RD STE 12
PHOENIX, AZ 85032-4799
United States

Phone: 602-457-4788 | Fax:
View Map External Link
Secondary Practice Address 13660 N 94TH DR SUITE B-1
PEORIA, AZ 85381-4836
United States

Phone: 623-977-2551 | Fax:
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Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 122300000X - Dentist AZ D009245
No 1223G0001X - Dentist General Practice AZ D009245