Provider Demographics
NPI:1407344567
Name:KIDS DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:KIDS DENTAL GROUP PLLC
Other - Org Name:MESA PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PONCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-234-6578
Mailing Address - Street 1:6025 N 27TH AVE STE 25
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-1765
Mailing Address - Country:US
Mailing Address - Phone:602-595-9199
Mailing Address - Fax:
Practice Address - Street 1:6239 E BROWN RD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4933
Practice Address - Country:US
Practice Address - Phone:480-396-3660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty