1396957577 NPI number — OCOTILLO FAMILY DENTISTRY LLC

Table of content: (NPI 1396957577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396957577 NPI number — OCOTILLO FAMILY DENTISTRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCOTILLO FAMILY DENTISTRY 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:
Provider Other Organization Name Type Code:
6
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:
1396957577
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:
995 E OCOTILLO RD
Provider Second Line Business Mailing Address:
SUITE #3
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85249-3111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-802-8686
Provider Business Mailing Address Fax Number:
480-802-8688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 E OCOTILLO RD
Provider Second Line Business Practice Location Address:
SUITE #3
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85249-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-802-8686
Provider Business Practice Location Address Fax Number:
480-802-8688
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NADARAJAN
Authorized Official First Name:
GIRIJA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER OWNER
Authorized Official Telephone Number:
480-802-8686

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1886702 . This is a "UCCI" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 78195 . This is a "DHA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com