Provider Demographics
NPI:1578839148
Name:EAST VALLEY PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:EAST VALLEY PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-632-7500
Mailing Address - Street 1:1355 S HIGLEY RD
Mailing Address - Street 2:STE 117
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4799
Mailing Address - Country:US
Mailing Address - Phone:480-632-7500
Mailing Address - Fax:480-632-8900
Practice Address - Street 1:1355 S HIGLEY RD
Practice Address - Street 2:STE 117
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4799
Practice Address - Country:US
Practice Address - Phone:480-632-7500
Practice Address - Fax:480-632-8900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD054101223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty