1225352289 NPI number — CROFT ORTHODONTICS PLLC

Table of content: (NPI 1225352289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225352289 NPI number — CROFT ORTHODONTICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROFT ORTHODONTICS PLLC
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:
VISTANCIA ORTHODONTICS
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:
1225352289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9772 W YEARLING RD STE A1600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85383-1380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-566-0800
Provider Business Mailing Address Fax Number:
623-566-0860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9772 W YEARLING RD
Provider Second Line Business Practice Location Address:
STE A1600
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85383-1380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-566-0800
Provider Business Practice Location Address Fax Number:
833-330-2854
Provider Enumeration Date:
03/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CROFT
Authorized Official First Name:
DEVIN
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
623-566-0800

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  7616 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 162964 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 518939 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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