Provider Demographics
NPI:1417176199
Name:SCORESBY PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:SCORESBY PEDIATRIC DENTAL
Other - Org Name:CHANDLER PEDIATRIC DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SCORESBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-855-8315
Mailing Address - Street 1:655 S DOBSON RD
Mailing Address - Street 2:BUILDING B SUITE 214
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5667
Mailing Address - Country:US
Mailing Address - Phone:480-855-1315
Mailing Address - Fax:480-855-8316
Practice Address - Street 1:2095 W FRYE RD STE 2
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6280
Practice Address - Country:US
Practice Address - Phone:480-855-8315
Practice Address - Fax:480-855-8316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD79621223P0221X
AZ1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ535113Medicaid
AZ814503Medicaid