Provider Demographics
NPI:1720565294
Name:ARIZONA MOBILE DENTAL SERVICES
Entity Type:Organization
Organization Name:ARIZONA MOBILE DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-899-7996
Mailing Address - Street 1:2010 E ELLIOT RD STE 105
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1790
Mailing Address - Country:US
Mailing Address - Phone:480-899-7996
Mailing Address - Fax:
Practice Address - Street 1:2010 E ELLIOT RD STE 105
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-1790
Practice Address - Country:US
Practice Address - Phone:480-899-7996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009270261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental