Provider Demographics
NPI:1164761383
Name:WILD WEST ORTHODONTICS INC.
Entity Type:Organization
Organization Name:WILD WEST ORTHODONTICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:AYOUB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-536-2040
Mailing Address - Street 1:14122 W MCDOWELL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2505
Mailing Address - Country:US
Mailing Address - Phone:623-536-2040
Mailing Address - Fax:623-536-8555
Practice Address - Street 1:14122 W MCDOWELL RD STE 200
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2505
Practice Address - Country:US
Practice Address - Phone:623-536-2040
Practice Address - Fax:623-536-8555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ00085821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1215184528OtherTYPE 1 NPI