Provider Demographics
NPI:1376601450
Name:THE DENTIST, L.L.C.
Entity Type:Organization
Organization Name:THE DENTIST, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:FRKETLICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-331-7001
Mailing Address - Street 1:9838 N 19TH AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-1936
Mailing Address - Country:US
Mailing Address - Phone:602-331-7007
Mailing Address - Fax:602-331-7001
Practice Address - Street 1:9838 N 19TH AVE
Practice Address - Street 2:SUITE K
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-1936
Practice Address - Country:US
Practice Address - Phone:602-331-7007
Practice Address - Fax:602-331-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty