Provider Demographics
NPI:1497962971
Name:DYSART DENTAL, LLC
Entity Type:Organization
Organization Name:DYSART DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:BRY
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-935-0500
Mailing Address - Street 1:5220 N. DYSART RD.
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340
Mailing Address - Country:US
Mailing Address - Phone:623-935-0500
Mailing Address - Fax:623-535-3897
Practice Address - Street 1:5220 N. DYSART RD.
Practice Address - Street 2:SUITE 160
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340
Practice Address - Country:US
Practice Address - Phone:623-935-0500
Practice Address - Fax:623-535-3897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6715122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty