Provider Demographics
NPI:1033508031
Name:TEPHROCACTUS LLC
Entity Type:Organization
Organization Name:TEPHROCACTUS LLC
Other - Org Name:GILBERT ROAD DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JASEN
Authorized Official - Middle Name:
Authorized Official - Last Name:STIGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-225-0595
Mailing Address - Street 1:PO BOX 61025
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-1025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2158 N GILBERT RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-2109
Practice Address - Country:US
Practice Address - Phone:480-649-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF0005391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty