Provider Demographics
NPI:1417055294
Name:SOUTHERN ARIZONA PERIODONTICS PLC
Entity Type:Organization
Organization Name:SOUTHERN ARIZONA PERIODONTICS PLC
Other - Org Name:COLE AND SHARP PLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENWALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-322-9300
Mailing Address - Street 1:5225 E KNIGHT DR
Mailing Address - Street 2:STE #401
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-322-9300
Mailing Address - Fax:520-322-6889
Practice Address - Street 1:5225 E KNIGHT DR
Practice Address - Street 2:STE #401
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-322-9300
Practice Address - Fax:520-322-6889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40871223P0300X
AZ25911223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty