Provider Demographics
NPI: | 1518289750 |
---|---|
Name: | IMAGE DENTISTRY OF GLENDALE, PC |
Entity Type: | Organization |
Organization Name: | IMAGE DENTISTRY OF GLENDALE, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | DAVID |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | FARBER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 602-298-7200 |
Mailing Address - Street 1: | 6120 W BELL RD |
Mailing Address - Street 2: | SUITE 180 |
Mailing Address - City: | GLENDALE |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85308-3781 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 602-298-7200 |
Mailing Address - Fax: | 602-298-7202 |
Practice Address - Street 1: | 6120 W BELL RD |
Practice Address - Street 2: | SUITE 180 |
Practice Address - City: | GLENDALE |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85308-3781 |
Practice Address - Country: | US |
Practice Address - Phone: | 602-298-7200 |
Practice Address - Fax: | 602-298-7202 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-02-15 |
Last Update Date: | 2010-02-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | D5085 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |