Provider Demographics
NPI:1508418625
Name:AZ GW ORTHO LLC
Entity Type:Organization
Organization Name:AZ GW ORTHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:EBONIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-553-3607
Mailing Address - Street 1:2218 E WILLIAMS FIELD RD STE 260
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-0779
Mailing Address - Country:US
Mailing Address - Phone:480-632-6868
Mailing Address - Fax:
Practice Address - Street 1:3329 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2633
Practice Address - Country:US
Practice Address - Phone:480-632-6868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-09
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty