Provider Demographics
NPI:1063015576
Name:STARLIGHT DENTAL SERVICES INC
Entity Type:Organization
Organization Name:STARLIGHT DENTAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TAE
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:424-392-2715
Mailing Address - Street 1:3440 W CACTUS RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-2238
Mailing Address - Country:US
Mailing Address - Phone:623-688-3364
Mailing Address - Fax:623-244-0333
Practice Address - Street 1:3440 W CACTUS RD STE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-2238
Practice Address - Country:US
Practice Address - Phone:623-688-3364
Practice Address - Fax:623-244-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2023-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2020P06513OtherARIZONA DEPARTMENT OF PUBLIC SAFETY