Provider Demographics
NPI:1316582323
Name:GREEN VALLEY DENTAL SPECIALTIES
Entity Type:Organization
Organization Name:GREEN VALLEY DENTAL SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-625-2311
Mailing Address - Street 1:101 S LA CANADA DR STE 54
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-2664
Mailing Address - Country:US
Mailing Address - Phone:520-625-2311
Mailing Address - Fax:520-625-2090
Practice Address - Street 1:101 S LA CANADA DR STE 54
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-2664
Practice Address - Country:US
Practice Address - Phone:520-625-2311
Practice Address - Fax:520-625-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty