Provider Demographics
NPI:1437500915
Name:ARIZONA PEDIATRIC DENTAL CARE
Entity Type:Organization
Organization Name:ARIZONA PEDIATRIC DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:W
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-917-9339
Mailing Address - Street 1:3011 S LINDSAY RD
Mailing Address - Street 2:108
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-4332
Mailing Address - Country:US
Mailing Address - Phone:480-917-9339
Mailing Address - Fax:480-821-2980
Practice Address - Street 1:3011 S LINDSAY RD
Practice Address - Street 2:108
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-4332
Practice Address - Country:US
Practice Address - Phone:480-917-9339
Practice Address - Fax:480-821-2980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ56851223P0221X
AZ87291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ821497Medicaid
AZ914227Medicaid