Provider Demographics
NPI:1538284971
Name:75TH AVENUE DENTISTRY, INC
Entity Type:Organization
Organization Name:75TH AVENUE DENTISTRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAROLL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GRAZIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-225-6555
Mailing Address - Street 1:23525 N. 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310
Mailing Address - Country:US
Mailing Address - Phone:623-225-6555
Mailing Address - Fax:
Practice Address - Street 1:7545 W. BELL RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-4764
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:2007-03-21
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5988122300000X
AZD6772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty