Provider Demographics
NPI:1629293477
Name:PECK FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:PECK FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-867-1398
Mailing Address - Street 1:14640 N TATUM BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4824
Mailing Address - Country:US
Mailing Address - Phone:602-867-1398
Mailing Address - Fax:602-867-1702
Practice Address - Street 1:14640 N TATUM BLVD STE 10
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4824
Practice Address - Country:US
Practice Address - Phone:602-867-1398
Practice Address - Fax:602-867-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4163 & 4181122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty