Provider Demographics
NPI:1285041020
Name:WESTERN DENTAL OF ARIZONA, INC.
Entity Type:Organization
Organization Name:WESTERN DENTAL OF ARIZONA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PPO COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SOLEDAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NAVARRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-480-3000
Mailing Address - Street 1:530 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4525
Mailing Address - Country:US
Mailing Address - Phone:714-480-3000
Mailing Address - Fax:714-571-6445
Practice Address - Street 1:1348 E FLORENCE BLVD
Practice Address - Street 2:7
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5361
Practice Address - Country:US
Practice Address - Phone:520-316-4287
Practice Address - Fax:520-316-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG92150Medicaid