1871931659 NPI number — SW MOBILE DA

Table of content: (NPI 1871931659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871931659 NPI number — SW MOBILE DA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SW MOBILE DA
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:
SOUTHWEST MOBILE DENTAL ANESTHESIOLOGY
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:
1871931659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13575 W INDIAN SCHOOL RD
Provider Second Line Business Mailing Address:
STE #1000
Provider Business Mailing Address City Name:
LITCHFIELD PARK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85340-4901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-652-6958
Provider Business Mailing Address Fax Number:
424-230-7849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13575 W INDIAN SCHOOL RD
Provider Second Line Business Practice Location Address:
STE #1000
Provider Business Practice Location Address City Name:
LITCHFIELD PARK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85340-4901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-652-6958
Provider Business Practice Location Address Fax Number:
424-230-7849
Provider Enumeration Date:
06/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BROWNSTEIN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
NEIL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-652-6958

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  D5164 , 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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