Provider Demographics
NPI:1760756209
Name:PEORIA DENTAL CENTER GROUP, LLC
Entity Type:Organization
Organization Name:PEORIA DENTAL CENTER GROUP, LLC
Other - Org Name:PEORIA DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RASOUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SALIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-877-5700
Mailing Address - Street 1:8914 N 91ST AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8390
Mailing Address - Country:US
Mailing Address - Phone:623-877-5700
Mailing Address - Fax:
Practice Address - Street 1:8914 N 91ST AVE STE 115
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8390
Practice Address - Country:US
Practice Address - Phone:623-877-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty