1659586774 NPI number — MARYLAND GARDEN DENTAL

Table of content: (NPI 1659586774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659586774 NPI number — MARYLAND GARDEN DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYLAND GARDEN DENTAL
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:
1659586774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
650 W MARYLAND AVE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85013-1399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-249-1616
Provider Business Mailing Address Fax Number:
602-249-1138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 W MARYLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85013-1399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-249-1616
Provider Business Practice Location Address Fax Number:
602-249-1138
Provider Enumeration Date:
05/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EFTEKHARI
Authorized Official First Name:
MASSOUD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
602-249-1616

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  4954 , 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: 450966 . This is a "HEALTH CHOICE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 250891 . This is a "CIGNA HMO" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 16354 . This is a "DORAL" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 169853 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com