Provider Demographics
NPI:1205408622
Name:IVY 2 DENTAL PLLC
Entity Type:Organization
Organization Name:IVY 2 DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:UMAR
Authorized Official - Middle Name:M
Authorized Official - Last Name:IMTIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-444-9999
Mailing Address - Street 1:23374 W YUMA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-3120
Mailing Address - Country:US
Mailing Address - Phone:623-444-9999
Mailing Address - Fax:623-444-6745
Practice Address - Street 1:405 E WETMORE RD STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-1700
Practice Address - Country:US
Practice Address - Phone:623-444-9999
Practice Address - Fax:623-444-6745
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVY 2 DENTAL, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty