Provider Demographics
NPI:1447598495
Name:HIGLEY VILLAGE KIDTASTIC, LLC
Entity Type:Organization
Organization Name:HIGLEY VILLAGE KIDTASTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-648-4037
Mailing Address - Street 1:4704 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2737
Mailing Address - Country:US
Mailing Address - Phone:480-648-4037
Mailing Address - Fax:480-696-5505
Practice Address - Street 1:3303 E QUEEN CREEK RD
Practice Address - Street 2:SUITE # 106
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-8532
Practice Address - Country:US
Practice Address - Phone:480-648-4037
Practice Address - Fax:480-696-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty