Provider Demographics
NPI:1073919452
Name:BAPTIST DENTAL CENTER, INC.
Entity Type:Organization
Organization Name:BAPTIST DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:J
Authorized Official - Last Name:HUH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-939-6215
Mailing Address - Street 1:7802 N 43RD AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-8111
Mailing Address - Country:US
Mailing Address - Phone:623-939-6215
Mailing Address - Fax:
Practice Address - Street 1:7802 N 43RD AVE STE 8
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-8111
Practice Address - Country:US
Practice Address - Phone:623-939-6215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD042841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102905Medicaid