1528392891 NPI number — KIDS DENTAL 2 P.C.

Table of content: (NPI 1528392891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528392891 NPI number — KIDS DENTAL 2 P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDS DENTAL 2 P.C.
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:
KIDS DENTAL PLACE
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:
1528392891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3130 E BASELINE RD
Provider Second Line Business Mailing Address:
#103-104
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85204-7290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-813-3423
Provider Business Mailing Address Fax Number:
480-718-7387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3130 E BASELINE RD
Provider Second Line Business Practice Location Address:
#103-104
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85204-7290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-813-3423
Provider Business Practice Location Address Fax Number:
480-718-7387
Provider Enumeration Date:
09/19/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AYOUB
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
RAYMOND
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
602-956-2024

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  6399 , 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)