Provider Demographics
NPI:1619485869
Name:THUNDERBIRD DENTAL STUDIO
Entity Type:Organization
Organization Name:THUNDERBIRD DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-906-9868
Mailing Address - Street 1:9179 W THUNDERBIRD RD STE 107
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4875
Mailing Address - Country:US
Mailing Address - Phone:623-933-6010
Mailing Address - Fax:
Practice Address - Street 1:9179 W THUNDERBIRD RD STE 107
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4875
Practice Address - Country:US
Practice Address - Phone:623-933-6010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD57221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty