Provider Demographics
NPI:1356885073
Name:BG DENTAL INCORPORATED
Entity type:Organization
Organization Name:BG DENTAL INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-881-6767
Mailing Address - Street 1:5255 E KNIGHT DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2147
Mailing Address - Country:US
Mailing Address - Phone:520-881-6767
Mailing Address - Fax:520-881-6767
Practice Address - Street 1:5255 E KNIGHT DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2147
Practice Address - Country:US
Practice Address - Phone:520-881-6767
Practice Address - Fax:520-881-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7359335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier