Provider Demographics
NPI:1821459421
Name:SUN WEST DENTAL SAN TAN
Entity Type:Organization
Organization Name:SUN WEST DENTAL SAN TAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-640-0267
Mailing Address - Street 1:2510 E HUNT HWY STE 28
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5208
Mailing Address - Country:US
Mailing Address - Phone:623-640-0267
Mailing Address - Fax:602-344-9713
Practice Address - Street 1:2510 E HUNT HWY
Practice Address - Street 2:SUITE #28
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5206
Practice Address - Country:US
Practice Address - Phone:480-355-0761
Practice Address - Fax:480-784-3883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty