Provider Demographics
NPI:1356501662
Name:A 19TH AVENUE DENTAL CARE
Entity Type:Organization
Organization Name:A 19TH AVENUE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:S
Authorized Official - Last Name:KAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-433-0313
Mailing Address - Street 1:5225 N 19TH AVENUE
Mailing Address - Street 2:#C
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015
Mailing Address - Country:US
Mailing Address - Phone:602-433-0313
Mailing Address - Fax:602-433-9343
Practice Address - Street 1:5225 N 19TH AVENUE
Practice Address - Street 2:#C
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015
Practice Address - Country:US
Practice Address - Phone:602-433-0313
Practice Address - Fax:602-433-9343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty