Provider Demographics
NPI:1366817967
Name:SWEET PEADIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:SWEET PEADIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJBOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-988-2828
Mailing Address - Street 1:1505 W SAINT MARYS RD # 178
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-3107
Mailing Address - Country:US
Mailing Address - Phone:253-988-2828
Mailing Address - Fax:
Practice Address - Street 1:15990 S RANCHO SAHUARITA BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SAHUARITA
Practice Address - State:AZ
Practice Address - Zip Code:85629-8022
Practice Address - Country:US
Practice Address - Phone:253-988-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9171261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental