Provider Demographics
NPI:1972128858
Name:BURGARDT AND DIAZ DENTAL GROUP, PLLC
Entity type:Organization
Organization Name:BURGARDT AND DIAZ DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, MANAGER, AND EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:GRAYSON
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BURGARDT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:620-260-5655
Mailing Address - Street 1:6519 E BLUEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-6741
Mailing Address - Country:US
Mailing Address - Phone:620-260-5655
Mailing Address - Fax:
Practice Address - Street 1:13260 N 94TH DR STE 410
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4241
Practice Address - Country:US
Practice Address - Phone:620-260-5655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-16
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty