Provider Demographics
NPI:1518366111
Name:EAST VALLEY DENTAL ANESTHESIA, PLLC
Entity Type:Organization
Organization Name:EAST VALLEY DENTAL ANESTHESIA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-518-5502
Mailing Address - Street 1:67 S HIGLEY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1166
Mailing Address - Country:US
Mailing Address - Phone:480-518-5502
Mailing Address - Fax:480-219-9234
Practice Address - Street 1:67 S HIGLEY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1166
Practice Address - Country:US
Practice Address - Phone:480-518-5502
Practice Address - Fax:480-219-9234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ56041223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty