1295281525 NPI number — WEST VALLEY ENDODONTICS AND ORAL SURGERY INC

Table of content: (NPI 1295281525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295281525 NPI number — WEST VALLEY ENDODONTICS AND ORAL SURGERY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST VALLEY ENDODONTICS AND ORAL SURGERY INC
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:
WEST VALLEY ENDODONTICS AND ORAL SURGERY
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:
1295281525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14122 W MCDOWELL RD
Provider Second Line Business Mailing Address:
201
Provider Business Mailing Address City Name:
GOODYEAR
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85395-2503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-444-4521
Provider Business Mailing Address Fax Number:
623-444-8304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14122 W. MCDOWELL RD.
Provider Second Line Business Practice Location Address:
201
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-444-4521
Provider Business Practice Location Address Fax Number:
623-444-8304
Provider Enumeration Date:
08/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RUIZ
Authorized Official First Name:
MARY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
REGIONAL MANAGER
Authorized Official Telephone Number:
602-418-1597

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  D5215 , 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)

  • Identifier: 5694444 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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