Provider Demographics
NPI:1083264154
Name:SCOTTSDALE DENTAL GROUP, PLC
Entity Type:Organization
Organization Name:SCOTTSDALE DENTAL GROUP, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:TERESE
Authorized Official - Last Name:EBNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:602-612-2262
Mailing Address - Street 1:4444 N 32ND ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3956
Mailing Address - Country:US
Mailing Address - Phone:602-612-2262
Mailing Address - Fax:602-581-3344
Practice Address - Street 1:4444 N 32ND ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3956
Practice Address - Country:US
Practice Address - Phone:602-612-2262
Practice Address - Fax:602-581-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ626192Medicaid