Provider Demographics
NPI:1750861233
Name:VAIL FAMILY DENTISTRY
Entity Type:Organization
Organization Name:VAIL FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-762-3236
Mailing Address - Street 1:13190 E COLOSSAL CAVE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-8822
Mailing Address - Country:US
Mailing Address - Phone:520-762-3236
Mailing Address - Fax:520-762-8058
Practice Address - Street 1:13190 E COLOSSAL CAVE RD STE 150
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-8822
Practice Address - Country:US
Practice Address - Phone:520-762-3236
Practice Address - Fax:520-762-8058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
AZD7579261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental