1164722021 NPI number — COUNTRY CLUB DENTAL MANAGEMENT CO, PC

Table of content: (NPI 1164722021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164722021 NPI number — COUNTRY CLUB DENTAL MANAGEMENT CO, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY CLUB DENTAL MANAGEMENT CO, PC
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:
Provider Other Organization Name Type Code:
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:
1164722021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4704 E SOUTHERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85206-2737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-889-9457
Provider Business Mailing Address Fax Number:
480-889-9493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4704 E SOUTHERN AVE
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-2737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-889-9457
Provider Business Practice Location Address Fax Number:
480-889-9493
Provider Enumeration Date:
10/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GROOP
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
480-889-9457

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D07819 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: D07819 , 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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