Provider Demographics
NPI:1235348830
Name:THIRD MILLENNIUM DENTAL GROUP
Entity Type:Organization
Organization Name:THIRD MILLENNIUM DENTAL GROUP
Other - Org Name:SMILE FITNESS DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-362-8200
Mailing Address - Street 1:8284 W UNION HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8170
Mailing Address - Country:US
Mailing Address - Phone:623-362-8200
Mailing Address - Fax:623-362-8244
Practice Address - Street 1:8284 W UNION HILLS DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8170
Practice Address - Country:US
Practice Address - Phone:623-362-8200
Practice Address - Fax:623-362-8244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty