Provider Demographics
NPI:1457474926
Name:BELL PARK DENTAL LLC
Entity Type:Organization
Organization Name:BELL PARK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTSHEKAN
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:602-896-9688
Mailing Address - Street 1:17037 N 43RD AVE STE A4
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4026
Mailing Address - Country:US
Mailing Address - Phone:602-896-9688
Mailing Address - Fax:602-896-9633
Practice Address - Street 1:17037 N 43RD AVE STE A4
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4026
Practice Address - Country:US
Practice Address - Phone:602-896-9688
Practice Address - Fax:602-896-9633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ408527OtherHOLLY BOTSHEKAN AHCCCS
AZ357980OtherRAMIN DAMADZADEH AHCCCS
AZ357980OtherRAMIN DAMADZADEH AHCCCS