Provider Demographics
NPI:1376019075
Name:EAST VALLEY IMPLANT & PERIODONTAL CENTER
Entity Type:Organization
Organization Name:EAST VALLEY IMPLANT & PERIODONTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-558-4504
Mailing Address - Street 1:3048 E BASELINE RD STE 112
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-7287
Mailing Address - Country:US
Mailing Address - Phone:480-558-4504
Mailing Address - Fax:480-827-9703
Practice Address - Street 1:3048 E BASELINE RD STE 112
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7287
Practice Address - Country:US
Practice Address - Phone:480-558-4504
Practice Address - Fax:480-827-9703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty