1942402094 NPI number — CONTINENTAL DENTAL CARE 19TH AVE LLC

Table of content: (NPI 1942402094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942402094 NPI number — CONTINENTAL DENTAL CARE 19TH AVE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONTINENTAL DENTAL CARE 19TH AVE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CONTINENTAL DENTAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942402094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5501 N 19TH AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85015-2450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-246-1119
Provider Business Mailing Address Fax Number:
602-249-5080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5501 N 19TH AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85015-2450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-246-1119
Provider Business Practice Location Address Fax Number:
602-249-5080
Provider Enumeration Date:
06/01/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VASQUEZ
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
623-326-8426

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  0213 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)