Provider Demographics
NPI:1376814012
Name:MODERN DENTAL PROFESSIONALS AZ, PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS AZ, PC
Other - Org Name:BRIGHTNOW CHRISTOWN SPECTRUM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-428-2000
Mailing Address - Street 1:1703 W BETHANY HOME RD
Mailing Address - Street 2:SUITE C01
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2566
Mailing Address - Country:US
Mailing Address - Phone:602-282-0042
Mailing Address - Fax:
Practice Address - Street 1:1703 W BETHANY HOME RD
Practice Address - Street 2:SUITE C01
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2566
Practice Address - Country:US
Practice Address - Phone:602-282-0042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty