Provider Demographics
NPI:1861658304
Name:ANTHEM DENTAL, LLC
Entity Type:Organization
Organization Name:ANTHEM DENTAL, LLC
Other - Org Name:CLASSICAL DENTISTRY OF ARIZONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAWNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-619-7023
Mailing Address - Street 1:41111 N DAISY MOUNTAIN DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-4957
Mailing Address - Country:US
Mailing Address - Phone:623-551-5444
Mailing Address - Fax:623-551-2522
Practice Address - Street 1:41111 N DAISY MOUNTAIN DR
Practice Address - Street 2:SUITE 105
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-4957
Practice Address - Country:US
Practice Address - Phone:623-551-5444
Practice Address - Fax:623-551-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD50021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty