Provider Demographics
NPI:1609236264
Name:ACES DENTAL OF FLAGSTAFF
Entity Type:Organization
Organization Name:ACES DENTAL OF FLAGSTAFF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VILAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SASTRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-440-5137
Mailing Address - Street 1:6127 S RAINBOW BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-3255
Mailing Address - Country:US
Mailing Address - Phone:702-998-2237
Mailing Address - Fax:702-243-2893
Practice Address - Street 1:1515 E CEDAR AVE
Practice Address - Street 2:UNIT C1
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1600
Practice Address - Country:US
Practice Address - Phone:928-440-5137
Practice Address - Fax:702-243-2893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009389261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental