Provider Demographics
NPI:1134499007
Name:GREAT GRINS CHILDREN'S DENTISTRY, P.L.L.C.
Entity Type:Organization
Organization Name:GREAT GRINS CHILDREN'S DENTISTRY, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:WOLFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-325-4746
Mailing Address - Street 1:3953 E PARADISE FALLS DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6688
Mailing Address - Country:US
Mailing Address - Phone:520-325-4746
Mailing Address - Fax:520-319-1031
Practice Address - Street 1:3953 E PARADISE FALLS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6688
Practice Address - Country:US
Practice Address - Phone:520-325-4746
Practice Address - Fax:520-319-1031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ66321223P0221X
AZ67421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ977473Medicaid
AZ967177Medicaid