Provider Demographics
NPI:1497110662
Name:AZ RESTORATION DENTAL PLLC
Entity Type:Organization
Organization Name:AZ RESTORATION DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:MUSCATO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-992-2996
Mailing Address - Street 1:4910 E GREENWAY RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1653
Mailing Address - Country:US
Mailing Address - Phone:602-992-2996
Mailing Address - Fax:602-992-2228
Practice Address - Street 1:4910 E GREENWAY RD
Practice Address - Street 2:SUITE 7
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-1653
Practice Address - Country:US
Practice Address - Phone:602-992-2996
Practice Address - Fax:602-992-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4730305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ421595OtherAHCCCS