Provider Demographics
NPI:1073895629
Name:KIDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:KIDIATRIC DENTISTRY, PLLC
Other - Org Name:KIDIATRIC DENTISTRY, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-418-1592
Mailing Address - Street 1:913 E WARNER RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3078
Mailing Address - Country:US
Mailing Address - Phone:602-418-1599
Mailing Address - Fax:
Practice Address - Street 1:913 E WARNER RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3078
Practice Address - Country:US
Practice Address - Phone:602-418-1599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD77821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ436424Medicaid