1063637197 NPI number — ROLLINS & PETERSEN ORTHODONTICS PLC

Table of content: (NPI 1063637197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063637197 NPI number — ROLLINS & PETERSEN ORTHODONTICS PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROLLINS & PETERSEN ORTHODONTICS PLC
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:
PETERSEN AND ROLLINS ORTHODONTICS PC
Provider Other Organization Name Type Code:
4
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:
1063637197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6755 E SUPERSTITION SPRINGS BLVD
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-924-2880
Provider Business Mailing Address Fax Number:
480-924-5634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6755 E SUPERSTITION SPRINGS BLVD
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-924-2880
Provider Business Practice Location Address Fax Number:
480-924-5634
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
ARLON
Authorized Official Middle Name:
M
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
480-924-2880

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  1961 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0400X , with the licence number: 4793 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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