Provider Demographics
NPI:1003224619
Name:CHILDREN'S DENTAL SPECIALTY GROUP LLC
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL SPECIALTY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-282-6746
Mailing Address - Street 1:7600 E CAMELBACK RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-2106
Mailing Address - Country:US
Mailing Address - Phone:480-282-6746
Mailing Address - Fax:
Practice Address - Street 1:7600 E CAMELBACK RD
Practice Address - Street 2:SUITE 8
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-2106
Practice Address - Country:US
Practice Address - Phone:480-282-6746
Practice Address - Fax:602-610-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-27
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD80061223P0221X
AZD0084641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ719559Medicaid
AZ533913Medicaid