Provider Demographics
NPI:1770628273
Name:THUNDERBIRD DENTAL TRUST
Entity Type:Organization
Organization Name:THUNDERBIRD DENTAL TRUST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRUSTEE
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-979-9454
Mailing Address - Street 1:13980 N 67TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3715
Mailing Address - Country:US
Mailing Address - Phone:623-979-9454
Mailing Address - Fax:623-979-9474
Practice Address - Street 1:13980 N 67TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3715
Practice Address - Country:US
Practice Address - Phone:623-979-9454
Practice Address - Fax:623-979-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty