Provider Demographics
NPI:1659586774
Name:MARYLAND GARDEN DENTAL
Entity Type:Organization
Organization Name:MARYLAND GARDEN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MASSOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:EFTEKHARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-249-1616
Mailing Address - Street 1:650 W MARYLAND AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1399
Mailing Address - Country:US
Mailing Address - Phone:602-249-1616
Mailing Address - Fax:602-249-1138
Practice Address - Street 1:650 W MARYLAND AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1399
Practice Address - Country:US
Practice Address - Phone:602-249-1616
Practice Address - Fax:602-249-1138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4954261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ450966OtherHEALTH CHOICE
AZ250891OtherCIGNA HMO
AZ16354OtherDORAL
AZ169853OtherUNITED CONCORDIA