Provider Demographics
NPI:1821135732
Name:PARADISE VALLEY DENTAL GROUP PC
Entity Type:Organization
Organization Name:PARADISE VALLEY DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST - OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:NESTLERODE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-483-8067
Mailing Address - Street 1:6865 E. BECKER LANE #100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254
Mailing Address - Country:US
Mailing Address - Phone:480-483-8067
Mailing Address - Fax:480-483-8471
Practice Address - Street 1:6865 E. BECKER LANE #100
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254
Practice Address - Country:US
Practice Address - Phone:480-483-8067
Practice Address - Fax:480-483-8471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ4495122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ410439OtherUNITED CONCORDIA
AZ40649OtherUNITED HEALTHCARE
AZAN1106702OtherDEA #