Provider Demographics
NPI:1043776644
Name:SOUTH TOWN DENTAL CARE, INC.
Entity Type:Organization
Organization Name:SOUTH TOWN DENTAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILDUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-391-4107
Mailing Address - Street 1:7205 E SOUTHERN AVE STE A-122
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-2790
Mailing Address - Country:US
Mailing Address - Phone:602-391-4107
Mailing Address - Fax:
Practice Address - Street 1:10720 W INDIAN SCHOOL RD STE 55
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5724
Practice Address - Country:US
Practice Address - Phone:623-877-1729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental