1306277918 NPI number — HERMOSA DENTAL AND ORTHODONTICS GROUP LLC

Table of content: (NPI 1306277918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306277918 NPI number — HERMOSA DENTAL AND ORTHODONTICS GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERMOSA DENTAL AND ORTHODONTICS GROUP 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:
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:
1306277918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3415 W GLENDALE AVE
Provider Second Line Business Mailing Address:
30
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85051-8386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-242-0550
Provider Business Mailing Address Fax Number:
602-242-4965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3415 W GLENDALE AVE
Provider Second Line Business Practice Location Address:
30
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85051-8386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-242-0550
Provider Business Practice Location Address Fax Number:
602-242-4965
Provider Enumeration Date:
12/06/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SALIM
Authorized Official First Name:
RASOUL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
602-242-0550

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D5067 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0300X , with the licence number: D6876 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: D8403 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: D8369 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)