1013064393 NPI number — DENTAL MASTER DESIGN, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013064393 NPI number — DENTAL MASTER DESIGN, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL MASTER DESIGN, 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:
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:
1013064393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10567
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85064-0567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3420 E SHEA BLVD
Provider Second Line Business Practice Location Address:
SUITE 151
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85028-3345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-867-4317
Provider Business Practice Location Address Fax Number:
602-867-4319
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRIFFITHS
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
602-867-4317

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  4480 , 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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