Provider Demographics
NPI:1164722021
Name:COUNTRY CLUB DENTAL MANAGEMENT CO, PC
Entity Type:Organization
Organization Name:COUNTRY CLUB DENTAL MANAGEMENT CO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GROOP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-889-9457
Mailing Address - Street 1:4704 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2737
Mailing Address - Country:US
Mailing Address - Phone:480-889-9457
Mailing Address - Fax:480-889-9493
Practice Address - Street 1:4704 E SOUTHERN AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2737
Practice Address - Country:US
Practice Address - Phone:480-889-9457
Practice Address - Fax:480-889-9493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD07819122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty