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Provider Information for 1316033491

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: 1316033491

Calendar   Last Updated:  2017-02-06
  Certification Date: 


Name Value
NPI 1316033491
Enumeration Date 2006-10-05
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 1715 E PALMAIRE AVE
PHOENIX, AZ 85020-5532
United States

Phone: 602-569-5500 | Fax:
View Map External Link
Primary Practice Address 3845 N 32ND ST
PHOENIX, AZ 85018-4901
United States

Phone: 602-956-2050 | Fax: 602-956-6027
View Map External Link
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 1223G0001X - Dentist General Practice AZ 6958