Provider Demographics
NPI:1497046395
Name:AZ LIFE DENTISTRY, PLLC
Entity Type:Organization
Organization Name:AZ LIFE DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:ARDALAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-861-5261
Mailing Address - Street 1:13065 W MCDOWELL RD
Mailing Address - Street 2:BUILDING B, SUITE #112
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6439
Mailing Address - Country:US
Mailing Address - Phone:623-455-3600
Mailing Address - Fax:
Practice Address - Street 1:13065 W MCDOWELL RD
Practice Address - Street 2:BUILDING B, SUITE #112
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6439
Practice Address - Country:US
Practice Address - Phone:623-455-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty