Provider Demographics
NPI:1508021023
Name:NORTHSIDE FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:NORTHSIDE FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NAGESH
Authorized Official - Middle Name:
Authorized Official - Last Name:GIDWANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-582-8088
Mailing Address - Street 1:18631 N 19TH AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-5827
Mailing Address - Country:US
Mailing Address - Phone:623-582-8088
Mailing Address - Fax:623-582-5346
Practice Address - Street 1:18631 N 19TH AVE STE 108
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-5827
Practice Address - Country:US
Practice Address - Phone:623-582-8088
Practice Address - Fax:623-582-5346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty