Provider Demographics
NPI:1649775842
Name:AGAVE FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:AGAVE FAMILY DENTAL PLLC
Other - Org Name:AGAVE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-830-0262
Mailing Address - Street 1:855 E WARNER RD STE 104
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-0998
Mailing Address - Country:US
Mailing Address - Phone:480-389-2452
Mailing Address - Fax:
Practice Address - Street 1:855 E WARNER RD STE 104
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-0998
Practice Address - Country:US
Practice Address - Phone:480-389-2452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental