Provider Demographics
NPI:1669687240
Name:PRIMARY FAMILY DENTIST,LLC
Entity Type:Organization
Organization Name:PRIMARY FAMILY DENTIST,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCOS
Authorized Official - Middle Name:
Authorized Official - Last Name:GONDALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-249-3301
Mailing Address - Street 1:2902 W CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-3301
Mailing Address - Country:US
Mailing Address - Phone:602-249-3301
Mailing Address - Fax:602-249-1117
Practice Address - Street 1:2902 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-3301
Practice Address - Country:US
Practice Address - Phone:602-249-3301
Practice Address - Fax:602-249-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty