Provider Demographics
NPI:1871018887
Name:SUMMIT DENTAL SPECIALTY PLLC
Entity Type:Organization
Organization Name:SUMMIT DENTAL SPECIALTY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-669-6419
Mailing Address - Street 1:15810 S 45TH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7695
Mailing Address - Country:US
Mailing Address - Phone:480-893-3636
Mailing Address - Fax:480-893-3635
Practice Address - Street 1:15810 S 45TH ST STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7695
Practice Address - Country:US
Practice Address - Phone:480-893-3636
Practice Address - Fax:480-893-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD90641223E0200X
AZD061471223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty