Provider Demographics
NPI:1558995951
Name:PEDIATRIC DENTISTRY OF CASA GRANDE
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF CASA GRANDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-467-9383
Mailing Address - Street 1:695 E COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-2023
Mailing Address - Country:US
Mailing Address - Phone:520-876-5200
Mailing Address - Fax:
Practice Address - Street 1:695 E COTTONWOOD LN
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2023
Practice Address - Country:US
Practice Address - Phone:520-876-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental