Provider Demographics
NPI:1619091550
Name:KAZUKI MANAGEMENT LLC
Entity Type:Organization
Organization Name:KAZUKI MANAGEMENT LLC
Other - Org Name:GREAT SMILES DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:480-231-7020
Mailing Address - Street 1:3509 E ROCKY SLOPE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-7094
Mailing Address - Country:US
Mailing Address - Phone:480-231-7020
Mailing Address - Fax:480-704-2272
Practice Address - Street 1:14800 W MOUNTAIN VIEW BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4795
Practice Address - Country:US
Practice Address - Phone:623-933-5749
Practice Address - Fax:623-815-1220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-18
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7536000001Medicare NSC