Provider Demographics
NPI:1730490228
Name:NORTH GROVES DENTAL GROUP
Entity Type:Organization
Organization Name:NORTH GROVES DENTAL GROUP
Other - Org Name:GILBERT ROAD DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:KOLE
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-649-7200
Mailing Address - Street 1:2158 N GILBERT RD
Mailing Address - Street 2:STE 123
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203
Mailing Address - Country:US
Mailing Address - Phone:480-649-7200
Mailing Address - Fax:
Practice Address - Street 1:2158 N GILBERT RD
Practice Address - Street 2:STE 123
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203
Practice Address - Country:US
Practice Address - Phone:480-649-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7286261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental