Provider Demographics
NPI:1588733588
Name:MLADENOV, RADOSTIN ILIEV (RDH)
Entity type:Individual
Prefix:MR
First Name:RADOSTIN
Middle Name:ILIEV
Last Name:MLADENOV
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14195 W AMELIA AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-8447
Mailing Address - Country:US
Mailing Address - Phone:623-535-8438
Mailing Address - Fax:
Practice Address - Street 1:15182 N 75TH AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4722
Practice Address - Country:US
Practice Address - Phone:623-878-2400
Practice Address - Fax:623-878-3151
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH60001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice