Provider Demographics
NPI:1427414341
Name:FAMILT& ESTHETIC DENTISTRY
Entity Type:Organization
Organization Name:FAMILT& ESTHETIC DENTISTRY
Other - Org Name:LIFETIME SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELAVARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-878-6000
Mailing Address - Street 1:6666 W PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-7014
Mailing Address - Country:US
Mailing Address - Phone:623-878-6000
Mailing Address - Fax:623-773-2230
Practice Address - Street 1:6666 W PEORIA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-7014
Practice Address - Country:US
Practice Address - Phone:623-878-6000
Practice Address - Fax:623-773-2230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8667261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8667OtherDENTAL LICENSE