Provider Demographics
NPI:1619021490
Name:ARIZONA PEDIATRIC DENTISTRY AND ORTHODONTIC
Entity Type:Organization
Organization Name:ARIZONA PEDIATRIC DENTISTRY AND ORTHODONTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHASHI
Authorized Official - Middle Name:M
Authorized Official - Last Name:KAPUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-344-2000
Mailing Address - Street 1:4145 N 108TH AVE
Mailing Address - Street 2:BLDG K-101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5463
Mailing Address - Country:US
Mailing Address - Phone:623-344-2000
Mailing Address - Fax:623-344-2007
Practice Address - Street 1:4145 N 108TH AVE
Practice Address - Street 2:BLDG K-101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5463
Practice Address - Country:US
Practice Address - Phone:623-344-2000
Practice Address - Fax:623-344-2007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD38011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF00359Medicaid