Provider Demographics
NPI:1376752808
Name:DESERT SHORES DENTISTRY, PLLC
Entity Type:Organization
Organization Name:DESERT SHORES DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SANDVIK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-759-2000
Mailing Address - Street 1:16515 S 40TH ST
Mailing Address - Street 2:STE. 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0558
Mailing Address - Country:US
Mailing Address - Phone:480-759-2000
Mailing Address - Fax:480-759-2058
Practice Address - Street 1:16515 S 40TH ST
Practice Address - Street 2:STE. 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0558
Practice Address - Country:US
Practice Address - Phone:480-759-2000
Practice Address - Fax:480-759-2058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ56761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty