Provider Demographics
NPI:1710146188
Name:MOUNTAIN PARK HEALTH CENTER - DENTAL
Entity Type:Organization
Organization Name:MOUNTAIN PARK HEALTH CENTER - DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SWAGERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-323-3470
Mailing Address - Street 1:3003 N CENTRAL AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2908
Mailing Address - Country:US
Mailing Address - Phone:602-323-3400
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:635 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-323-3299
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN PARK HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-02
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC0599261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)