1497122287 NPI number — G D DENTAL PLLC

Table of content: (NPI 1497122287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497122287 NPI number — G D DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G D DENTAL 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:
PHOENIX MIDTOWN DENTISTRY
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:
1497122287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5555 N 7TH ST
Provider Second Line Business Mailing Address:
STE 142
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85014-2584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-265-8566
Provider Business Mailing Address Fax Number:
602-248-0587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5555 N 7TH ST
Provider Second Line Business Practice Location Address:
STE 142
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85014-2584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-265-8566
Provider Business Practice Location Address Fax Number:
602-248-0587
Provider Enumeration Date:
08/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DARIAN
Authorized Official First Name:
GHASEM
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER/ DENTIST
Authorized Official Telephone Number:
602-265-8566

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D04354 , 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)





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