1083086920 NPI number — SV PEDIATRIC DENTISTRY, LLC

Table of content: JOHN DONOGHUE (NPI 1699596452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083086920 NPI number — SV PEDIATRIC DENTISTRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SV PEDIATRIC DENTISTRY, LLC
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:
6
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:
1083086920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4435 E HOLMES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85206-3372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-889-9457
Provider Business Mailing Address Fax Number:
480-696-5505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 S HIGLEY RD
Provider Second Line Business Practice Location Address:
SUITE #206
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-985-9110
Provider Business Practice Location Address Fax Number:
480-924-5709
Provider Enumeration Date:
10/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BALLARD
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CFO, CIO
Authorized Official Telephone Number:
480-889-9457

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)





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