Provider Demographics
NPI:1558996538
Name:ARIZONA DENTAL PROFESSIONALS, P.C.
Entity Type:Organization
Organization Name:ARIZONA DENTAL PROFESSIONALS, P.C.
Other - Org Name:BLACK MOUNTAIN DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:5355 E CAREFREE HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:CAREFREE
Mailing Address - State:AZ
Mailing Address - Zip Code:85331
Mailing Address - Country:US
Mailing Address - Phone:480-795-7180
Mailing Address - Fax:
Practice Address - Street 1:5355 E CAREFREE HWY STE 102
Practice Address - Street 2:
Practice Address - City:CAREFREE
Practice Address - State:AZ
Practice Address - Zip Code:85331
Practice Address - Country:US
Practice Address - Phone:480-795-7180
Practice Address - Fax:480-687-5311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-10
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty