1689875791 NPI number — CENTER FOR PEDIATRIC DENTISTRY, L.L.C.

Table of content: (NPI 1689875791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689875791 NPI number — CENTER FOR PEDIATRIC DENTISTRY, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR PEDIATRIC DENTISTRY, L.L.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:
Provider Other Organization Name Type Code:
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:
1689875791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2571 S VAL VISTA DR STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85295-6233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-597-5536
Provider Business Mailing Address Fax Number:
480-597-5624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2571 S VAL VISTA DR STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85295-6233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-597-5536
Provider Business Practice Location Address Fax Number:
480-597-5624
Provider Enumeration Date:
05/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ABDOLL
Authorized Official First Name:
KARLA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
480-597-5536

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 590291 . This is a "AHCCCS ID #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".