Provider Demographics
NPI:1548387384
Name:AVONDALE FAMILY DENTAL CARE PC.
Entity Type:Organization
Organization Name:AVONDALE FAMILY DENTAL CARE PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NAM-RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-932-3344
Mailing Address - Street 1:320 E WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-2348
Mailing Address - Country:US
Mailing Address - Phone:623-932-3344
Mailing Address - Fax:623-932-0594
Practice Address - Street 1:320 E WESTERN AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-2348
Practice Address - Country:US
Practice Address - Phone:623-932-3344
Practice Address - Fax:623-932-0594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ480476Medicaid