Provider Demographics
NPI:1417121880
Name:COUNTRY CLUB DENTAL INC.
Entity Type:Organization
Organization Name:COUNTRY CLUB DENTAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:JOANN
Authorized Official - Last Name:FATTOHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-892-8185
Mailing Address - Street 1:3050 S COUNTRY CLUB DR STE 18
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-8365
Mailing Address - Country:US
Mailing Address - Phone:480-892-8185
Mailing Address - Fax:
Practice Address - Street 1:3050 S COUNTRY CLUB DR STE 18
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-8365
Practice Address - Country:US
Practice Address - Phone:480-892-8185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty