Provider Demographics
NPI:1851526636
Name:SOLARIS MEDSPA
Entity Type:Organization
Organization Name:SOLARIS MEDSPA
Other - Org Name:SOLARIS DENTISTRY AND MEDSPA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCWILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:NMD, DO
Authorized Official - Phone:480-802-6617
Mailing Address - Street 1:4917 S ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-5632
Mailing Address - Country:US
Mailing Address - Phone:480-802-6617
Mailing Address - Fax:480-802-5711
Practice Address - Street 1:4917 S ALMA SCHOOL RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248
Practice Address - Country:US
Practice Address - Phone:480-802-6617
Practice Address - Fax:480-802-5711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ06934261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU47634Medicare UPIN