Provider Demographics
NPI:1508911710
Name:AYIYI, RICHARD A SR (CEO)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:AYIYI
Suffix:SR
Gender:M
Credentials:CEO
Other - Prefix:MR
Other - First Name:JACK
Other - Middle Name:G
Other - Last Name:WINDHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:GENERAL MANAGER
Mailing Address - Street 1:5270 N 59TH AVE
Mailing Address - Street 2:SUITE 18
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-6762
Mailing Address - Country:US
Mailing Address - Phone:623-934-5291
Mailing Address - Fax:623-847-9898
Practice Address - Street 1:5270 N 59TH AVE
Practice Address - Street 2:SUITE 18
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-6762
Practice Address - Country:US
Practice Address - Phone:623-934-5291
Practice Address - Fax:623-847-9898
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD63991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice