Provider Demographics
NPI:1225274913
Name:A & N SUNVALLEY DENTAL CENTER, INC.
Entity Type:Organization
Organization Name:A & N SUNVALLEY DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHESHTCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-921-3811
Mailing Address - Street 1:960 W UNIVERSITY DR
Mailing Address - Street 2:STE. #115
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-7808
Mailing Address - Country:US
Mailing Address - Phone:480-921-3811
Mailing Address - Fax:480-921-3830
Practice Address - Street 1:960 W UNIVERSITY DR
Practice Address - Street 2:STE. #115
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-7808
Practice Address - Country:US
Practice Address - Phone:480-921-3811
Practice Address - Fax:480-921-3830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5191302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ521858002Medicaid