Provider Demographics
NPI:1073982997
Name:EAST SCOTTSDALE PEDIATRIC DENTAL, PC
Entity Type:Organization
Organization Name:EAST SCOTTSDALE PEDIATRIC DENTAL, PC
Other - Org Name:DENTAL ASSOCIATES FOR KIDS ONLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:H
Authorized Official - Last Name:VENEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-850-5110
Mailing Address - Street 1:12020 E SHEA BLVD
Mailing Address - Street 2:STE 8
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-4179
Mailing Address - Country:US
Mailing Address - Phone:480-767-5600
Mailing Address - Fax:
Practice Address - Street 1:12020 E SHEA BLVD
Practice Address - Street 2:STE 8
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-4179
Practice Address - Country:US
Practice Address - Phone:480-767-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2015-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009209261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ064282Medicaid