Provider Demographics
NPI:1043623770
Name:IMAGINE DENTAL
Entity Type:Organization
Organization Name:IMAGINE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LILIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-633-9977
Mailing Address - Street 1:650 W MARYLAND AVE
Mailing Address - Street 2:1-2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1399
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 W MARYLAND AVE
Practice Address - Street 2:1-2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1399
Practice Address - Country:US
Practice Address - Phone:480-633-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL SPECIALTY ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD07028122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty