Provider Demographics
NPI:1689025256
Name:ARIZONA DENTAL ANESTHESIA PLLC
Entity Type:Organization
Organization Name:ARIZONA DENTAL ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-499-4044
Mailing Address - Street 1:14100 N 83RD AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5660
Mailing Address - Country:US
Mailing Address - Phone:602-499-4044
Mailing Address - Fax:
Practice Address - Street 1:14100 N 83RD AVE STE 280
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5660
Practice Address - Country:US
Practice Address - Phone:602-499-4044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ79901223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty