Provider Demographics
NPI:1639622103
Name:AZCDC,LLC
Entity Type:Organization
Organization Name:AZCDC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIS
Authorized Official - Prefix:DR
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-226-5652
Mailing Address - Street 1:POBOX 5132
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85385
Mailing Address - Country:US
Mailing Address - Phone:480-226-5652
Mailing Address - Fax:
Practice Address - Street 1:5700 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302
Practice Address - Country:US
Practice Address - Phone:480-226-5652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-01
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4274261QD0000X
NMDD4407261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental