1730378522 NPI number — DESERT DENTAL GROUP, P.C.

Table of content: (NPI 1730378522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730378522 NPI number — DESERT DENTAL GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT DENTAL GROUP, 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:
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:
1730378522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8265 S HOUGHTON RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85747-9702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-663-0419
Provider Business Mailing Address Fax Number:
520-663-0429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8265 S HOUGHTON RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85747-9702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-663-0419
Provider Business Practice Location Address Fax Number:
520-663-0429
Provider Enumeration Date:
10/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HAMPTON
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
520-663-0419

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5038 , 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: 100-5038 . This is a "DELTA DENTAL" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ 0490680 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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