Provider Demographics
NPI:1477075653
Name:BERTZ PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BERTZ PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-945-0663
Mailing Address - Street 1:3501 N SCOTTSDALE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-5649
Mailing Address - Country:US
Mailing Address - Phone:480-945-0663
Mailing Address - Fax:480-947-3991
Practice Address - Street 1:3501 N SCOTTSDALE RD STE 110
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-5649
Practice Address - Country:US
Practice Address - Phone:480-945-0663
Practice Address - Fax:480-947-3991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223S0112X
AZ12096204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty