Provider Demographics
NPI:1518105691
Name:AESTHETIC FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:AESTHETIC FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:RODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-515-0404
Mailing Address - Street 1:26232 N TATUM BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7504
Mailing Address - Country:US
Mailing Address - Phone:480-515-0404
Mailing Address - Fax:480-515-2587
Practice Address - Street 1:26232 N TATUM BLVD STE 400
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7504
Practice Address - Country:US
Practice Address - Phone:480-515-0404
Practice Address - Fax:480-515-2587
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AESTHETIC FAMILY DENTISTRY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty