Provider Demographics
NPI:1407994676
Name:DESERT STATE DENTAL ANESTHESIA, LLC
Entity Type:Organization
Organization Name:DESERT STATE DENTAL ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-332-5541
Mailing Address - Street 1:625 W SOUTHERN AVE STE E-145
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-5030
Mailing Address - Country:US
Mailing Address - Phone:480-332-5541
Mailing Address - Fax:866-814-1886
Practice Address - Street 1:625 W SOUTHERN AVE STE E-145
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5030
Practice Address - Country:US
Practice Address - Phone:480-332-5541
Practice Address - Fax:866-814-1886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ884644Medicaid