Provider Demographics
NPI:1417462664
Name:NEW IMAGE DENTISTRY PLLC
Entity Type:Organization
Organization Name:NEW IMAGE DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-825-9445
Mailing Address - Street 1:17235 N 75TH AVE STE A100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-0884
Mailing Address - Country:US
Mailing Address - Phone:623-825-9445
Mailing Address - Fax:623-825-9446
Practice Address - Street 1:17235 N 75TH AVE STE A100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-0884
Practice Address - Country:US
Practice Address - Phone:623-825-9445
Practice Address - Fax:623-825-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental