1922303569 NPI number — TOTAL FREEDOM DENTAL IMPLANT CENTER

Table of content: (NPI 1922303569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922303569 NPI number — TOTAL FREEDOM DENTAL IMPLANT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOTAL FREEDOM DENTAL IMPLANT CENTER
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:
1922303569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9002 E DESERT COVE AVE
Provider Second Line Business Mailing Address:
#101
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85260-6710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-860-9002
Provider Business Mailing Address Fax Number:
480-451-9378

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9002 E DESERT COVE AVE
Provider Second Line Business Practice Location Address:
#101
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85260-6710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-860-9002
Provider Business Practice Location Address Fax Number:
480-451-9378
Provider Enumeration Date:
01/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SIMS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
480-860-9002

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3573 , 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: 277697 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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