Provider Demographics
NPI:1235641937
Name:KETHCART SLEEP LLC
Entity Type:Organization
Organization Name:KETHCART SLEEP LLC
Other - Org Name:CENTRAL PHOENIX CENTER FOR TMJ, PAIN & SLEEP DISORDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGAING MEMBER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER KETHCART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-615-8516
Mailing Address - Street 1:1277 E MISSOURI AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2916
Mailing Address - Country:US
Mailing Address - Phone:602-615-8516
Mailing Address - Fax:602-883-7252
Practice Address - Street 1:1277 E MISSOURI AVE STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2916
Practice Address - Country:US
Practice Address - Phone:602-615-8516
Practice Address - Fax:602-883-7252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
AZD6695332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty