Provider Demographics
NPI:1144757196
Name:ASHWAQ DENTAL ONE, LLC
Entity Type:Organization
Organization Name:ASHWAQ DENTAL ONE, LLC
Other - Org Name:SMILES OF ANTHEM FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ISAIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAYAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-317-3890
Mailing Address - Street 1:PO BOX 5279
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85385-5279
Mailing Address - Country:US
Mailing Address - Phone:1602-317-3890
Mailing Address - Fax:
Practice Address - Street 1:42104 N VENTURE DR STE B118
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3828
Practice Address - Country:US
Practice Address - Phone:623-742-6800
Practice Address - Fax:844-273-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-20
Last Update Date:2017-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental