Provider Demographics
NPI:1407632896
Name:ANTHEM DENTIST
Entity Type:Organization
Organization Name:ANTHEM DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-363-2145
Mailing Address - Street 1:42201 N 41ST DR STE 156
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3803
Mailing Address - Country:US
Mailing Address - Phone:623-551-3511
Mailing Address - Fax:623-551-3513
Practice Address - Street 1:42201 N 41ST DR STE 156
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3803
Practice Address - Country:US
Practice Address - Phone:623-551-3511
Practice Address - Fax:623-551-3513
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIVADENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty