Provider Demographics
NPI:1083799639
Name:FLAGSTAFF ENDODONTICS
Entity Type:Organization
Organization Name:FLAGSTAFF ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MS
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-774-4400
Mailing Address - Street 1:1600 W UNIVERSITY AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3154
Mailing Address - Country:US
Mailing Address - Phone:928-774-4400
Mailing Address - Fax:928-774-5436
Practice Address - Street 1:1600 W UNIVERSITY AVE STE 103
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3154
Practice Address - Country:US
Practice Address - Phone:928-774-4400
Practice Address - Fax:928-774-5436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21971223E0200X
AZ65311223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2197OtherDENTAL LICENSE NO.
AZ6531OtherDENTAL LICENSE NO.