Provider Demographics
NPI:1831310879
Name:GENGLE, MICHAEL J (PA-C, DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:GENGLE
Suffix:
Gender:M
Credentials:PA-C, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10488 E MERCER LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-6509
Mailing Address - Country:US
Mailing Address - Phone:623-680-4831
Mailing Address - Fax:
Practice Address - Street 1:9787 N 91ST ST
Practice Address - Street 2:# 101
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5088
Practice Address - Country:US
Practice Address - Phone:480-845-0429
Practice Address - Fax:480-563-8009
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD30231223G0001X
AZ5304363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1223G0001XDental ProvidersDentistGeneral Practice