Provider Demographics
NPI:1851780852
Name:AGAVE DENTAL LLC
Entity Type:Organization
Organization Name:AGAVE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-914-4274
Mailing Address - Street 1:PO BOX 61025
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-1025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4235 N 32ND ST
Practice Address - Street 2:SUITE C
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-4766
Practice Address - Country:US
Practice Address - Phone:602-957-2411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF0003751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty