1760918965 NPI number — IVY 2 DENTAL PLLC

Table of content: (NPI 1760918965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760918965 NPI number — IVY 2 DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IVY 2 DENTAL 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:
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:
1760918965
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17570 N 75TH AVE
Provider Second Line Business Mailing Address:
SUITE E500
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85308-5999
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-322-9919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17570 N 75TH AVE
Provider Second Line Business Practice Location Address:
SUITE E500
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-5999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-322-9919
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2017

Additional Information

Authorized Official

Authorized Official Last Name:
IMTIAZ
Authorized Official First Name:
UMAR
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ASSOCIATE PROVIDER
Authorized Official Telephone Number:
623-444-9999

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  7256 , 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: 274819 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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