Provider Demographics
NPI:1114320504
Name:ARIZONA DENTAL PROFESSIONALS, P.C.
Entity Type:Organization
Organization Name:ARIZONA DENTAL PROFESSIONALS, P.C.
Other - Org Name:SANTA CRUZ RIVER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8513
Mailing Address - Street 1:1185 W IRVINGTON RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85714-1278
Mailing Address - Country:US
Mailing Address - Phone:520-247-2328
Mailing Address - Fax:
Practice Address - Street 1:1185 W IRVINGTON RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-1278
Practice Address - Country:US
Practice Address - Phone:520-247-2328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-30
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty