Provider Demographics
NPI:1083060339
Name:IMPRESSIONS AT CASA GRANDE PLC
Entity Type:Organization
Organization Name:IMPRESSIONS AT CASA GRANDE PLC
Other - Org Name:IMPRESSIONS DENTAL CG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:D
Authorized Official - Last Name:WEED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-374-2400
Mailing Address - Street 1:1677 E FLORENCE BLVD STE 24
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-4786
Mailing Address - Country:US
Mailing Address - Phone:520-374-2400
Mailing Address - Fax:520-836-7469
Practice Address - Street 1:1677 E FLORENCE BLVD STE 24
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4786
Practice Address - Country:US
Practice Address - Phone:520-374-2400
Practice Address - Fax:520-836-7469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty