Provider Demographics
NPI:1669495636
Name:GRAND DENTAL CARE, PC
Entity Type:Organization
Organization Name:GRAND DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:E
Authorized Official - Last Name:WESSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-972-2156
Mailing Address - Street 1:10615 W THUNDERBIRD BLVD
Mailing Address - Street 2:B-500
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3033
Mailing Address - Country:US
Mailing Address - Phone:623-972-2156
Mailing Address - Fax:623-972-6952
Practice Address - Street 1:10615 W THUNDERBIRD BLVD
Practice Address - Street 2:B-500
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3033
Practice Address - Country:US
Practice Address - Phone:623-972-2156
Practice Address - Fax:623-972-6952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty