Provider Demographics
NPI:1528204591
Name:ARROWHEAD DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:ARROWHEAD DENTAL GROUP, LLC
Other - Org Name:75TH AVENUE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:FAWNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:MGR
Authorized Official - Phone:623-582-3902
Mailing Address - Street 1:7545 W BELL RD
Mailing Address - Street 2:#105
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3832
Mailing Address - Country:US
Mailing Address - Phone:623-412-2461
Mailing Address - Fax:623-979-7364
Practice Address - Street 1:7545 W BELL RD
Practice Address - Street 2:#105
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3832
Practice Address - Country:US
Practice Address - Phone:623-412-2461
Practice Address - Fax:623-979-7364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty