Provider Demographics
NPI:1245496504
Name:FLETCHER, ADRIAN BENEDICT (DMD)
Entity type:Individual
Prefix:MR
First Name:ADRIAN
Middle Name:BENEDICT
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 N CENTRAL AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3313
Mailing Address - Country:US
Mailing Address - Phone:602-279-5262
Mailing Address - Fax:
Practice Address - Street 1:4041 N CENTRAL AVE BLDG C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3313
Practice Address - Country:US
Practice Address - Phone:602-279-5262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3945122300000X, 1223G0001X
AZD0098621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35038357Medicaid