Provider Demographics
NPI:1083182315
Name:DENTAL HOME, LLC
Entity Type:Organization
Organization Name:DENTAL HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:HULL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-615-0651
Mailing Address - Street 1:13821 N MOON DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-7120
Mailing Address - Country:US
Mailing Address - Phone:602-615-0651
Mailing Address - Fax:
Practice Address - Street 1:720 E THUNDERBIRD RD STE 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-5396
Practice Address - Country:US
Practice Address - Phone:602-863-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental