1174771612 NPI number — KATSUR DENTAL OF ARIZONA, INC.

Table of content: (NPI 1174771612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174771612 NPI number — KATSUR DENTAL OF ARIZONA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KATSUR DENTAL OF ARIZONA, INC.
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:
KATSUR DENTAL OF ARIZONA
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:
1174771612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
926 GREAT POND DR
Provider Second Line Business Mailing Address:
SUITE 5000
Provider Business Mailing Address City Name:
ALTAMONTE SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32714-7244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-772-5124
Provider Business Mailing Address Fax Number:
407-788-3572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 N LITCHFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85338-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-932-3200
Provider Business Practice Location Address Fax Number:
623-932-3222
Provider Enumeration Date:
09/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GARDINER
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
407-772-5124

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5795 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 5216 , 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: 565806 . This is a "SANTORO AHCCCS#" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 294311 . This is a "LOAN KIM DAO AHCCCS#" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 197645 . This is a "ONET AHCCCS#" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 506058 . This is a "TURNER AHCCCS#" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 368780 . This is a "GROUP AHCCCS#" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 561921 . This is a "WHATCOTT AHCCCS#" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 774457 . This is a "SKAALEN AHCCCS#" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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