Provider Demographics
NPI:1972916690
Name:PHOENIX DENTAL GROUP LLC
Entity Type:Organization
Organization Name:PHOENIX DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSEF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-232-1980
Mailing Address - Street 1:1423 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-3004
Mailing Address - Country:US
Mailing Address - Phone:602-232-1980
Mailing Address - Fax:
Practice Address - Street 1:5115 N DYSART RD
Practice Address - Street 2:SUITE 202-142
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-3032
Practice Address - Country:US
Practice Address - Phone:602-232-1980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty