Provider Demographics
NPI:1790959435
Name:AGAVE DENTISTRY
Entity Type:Organization
Organization Name:AGAVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DUKA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-876-9955
Mailing Address - Street 1:2028 N TREKELL RD
Mailing Address - Street 2:#107/#108
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-1326
Mailing Address - Country:US
Mailing Address - Phone:520-876-9955
Mailing Address - Fax:
Practice Address - Street 1:2028 N TREKELL RD
Practice Address - Street 2:#107/#108
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-1326
Practice Address - Country:US
Practice Address - Phone:520-876-9955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty