Provider Demographics
NPI:1528189248
Name:SUN CITY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SUN CITY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:AGNIESZKA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAWERSKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-972-1558
Mailing Address - Street 1:2826 N 151ST AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-2061
Mailing Address - Country:US
Mailing Address - Phone:623-535-1705
Mailing Address - Fax:
Practice Address - Street 1:10228 W COGGINS DR
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3421
Practice Address - Country:US
Practice Address - Phone:623-972-1558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD62491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ151409OtherAHCCCS