Provider Demographics
NPI:1073836110
Name:CEDAR DENTAL GROUP, PC
Entity Type:Organization
Organization Name:CEDAR DENTAL GROUP, PC
Other - Org Name:M & C COMMUNITY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:AYOUB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-307-5775
Mailing Address - Street 1:333 E VIRGINIA AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1206
Mailing Address - Country:US
Mailing Address - Phone:602-307-5775
Mailing Address - Fax:602-307-9041
Practice Address - Street 1:333 E VIRGINIA AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1206
Practice Address - Country:US
Practice Address - Phone:602-307-5775
Practice Address - Fax:602-307-9041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ951500OtherAHCCCS PROVIDER NUMBER