Provider Demographics
NPI:1598168981
Name:ARIZONA DENTAL PROFESSIONALS, P.C.
Entity Type:Organization
Organization Name:ARIZONA DENTAL PROFESSIONALS, P.C.
Other - Org Name:DENTAL VILLAGE - NORTHWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:5209 N ORACLE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3707
Mailing Address - Country:US
Mailing Address - Phone:520-293-9277
Mailing Address - Fax:
Practice Address - Street 1:5209 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3707
Practice Address - Country:US
Practice Address - Phone:520-293-9277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty