Provider Demographics
NPI:1790010809
Name:ACADEMY DENTAL - PERFECT TEETH PC
Entity Type:Organization
Organization Name:ACADEMY DENTAL - PERFECT TEETH PC
Other - Org Name:PERFECT TEETH - NORTH WILMOT PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:ARBUCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-285-6098
Mailing Address - Street 1:6126 E. SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-298-2379
Mailing Address - Fax:520-298-7332
Practice Address - Street 1:6126 E. SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-298-2379
Practice Address - Fax:520-298-7332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO60971223G0001X
AZ48211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty