Provider Demographics
NPI:1275084501
Name:THUNDERBIRD DENTAL MANAGEMENT LLC
Entity Type:Organization
Organization Name:THUNDERBIRD DENTAL MANAGEMENT LLC
Other - Org Name:PLAZA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-634-4803
Mailing Address - Street 1:9145 W THUNDERBIRD RD
Mailing Address - Street 2:SUITE H-105
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4820
Mailing Address - Country:US
Mailing Address - Phone:623-979-7477
Mailing Address - Fax:
Practice Address - Street 1:9145 W THUNDERBIRD RD
Practice Address - Street 2:SUITE H-105
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4820
Practice Address - Country:US
Practice Address - Phone:623-979-7477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0092441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty