Provider Demographics
NPI:1760084255
Name:ARIZONA SPECIAL DENTISTRY AND SURGERY LLC
Entity Type:Organization
Organization Name:ARIZONA SPECIAL DENTISTRY AND SURGERY LLC
Other - Org Name:ARIZONA SPECIAL DENTISTRY AND SURGERY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-637-2100
Mailing Address - Street 1:4550 E BELL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9342
Mailing Address - Country:US
Mailing Address - Phone:602-485-1588
Mailing Address - Fax:
Practice Address - Street 1:4550 E BELL RD STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9342
Practice Address - Country:US
Practice Address - Phone:602-485-1588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ586868Medicaid