Provider Demographics
NPI:1083094205
Name:ENHOUSE DENTAL LLC
Entity Type:Organization
Organization Name:ENHOUSE DENTAL LLC
Other - Org Name:DENTAL ON CENTRAL TATUM POINT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KOZERSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-266-1776
Mailing Address - Street 1:5133 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1438
Mailing Address - Country:US
Mailing Address - Phone:602-507-6155
Mailing Address - Fax:602-507-6156
Practice Address - Street 1:4747 E BELL RD
Practice Address - Street 2:SUITE 7
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2301
Practice Address - Country:US
Practice Address - Phone:602-507-6155
Practice Address - Fax:602-507-6155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty