Provider Demographics
NPI:1437732054
Name:STATE 48 DENTAL PLLC
Entity Type:Organization
Organization Name:STATE 48 DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-312-1348
Mailing Address - Street 1:5122 N 95TH AVE STE A100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-3044
Mailing Address - Country:US
Mailing Address - Phone:602-312-1348
Mailing Address - Fax:
Practice Address - Street 1:5122 N 95TH AVE STE A100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-3044
Practice Address - Country:US
Practice Address - Phone:602-312-1348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental