Provider Demographics
NPI:1760918965
Name:IVY 2 DENTAL PLLC
Entity Type:Organization
Organization Name:IVY 2 DENTAL PLLC
Other - Org Name:CIRCLE DENTAL, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ASSOCIATE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:UMAR
Authorized Official - Middle Name:M
Authorized Official - Last Name:IMTIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-444-9999
Mailing Address - Street 1:17570 N 75TH AVE
Mailing Address - Street 2:SUITE E500
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5999
Mailing Address - Country:US
Mailing Address - Phone:623-322-9919
Mailing Address - Fax:
Practice Address - Street 1:17570 N 75TH AVE
Practice Address - Street 2:SUITE E500
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5999
Practice Address - Country:US
Practice Address - Phone:623-322-9919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVY 2 DENTAL PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-08
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7256122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ274819Medicaid