Provider Demographics
NPI:1891121422
Name:NOVA DENTAL INCORPORATED
Entity Type:Organization
Organization Name:NOVA DENTAL INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUO
Authorized Official - Middle Name:
Authorized Official - Last Name:JI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:520-325-1098
Mailing Address - Street 1:4411 E 5TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2015
Mailing Address - Country:US
Mailing Address - Phone:520-325-1098
Mailing Address - Fax:520-325-1112
Practice Address - Street 1:4411 E 5TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2015
Practice Address - Country:US
Practice Address - Phone:520-325-1098
Practice Address - Fax:520-325-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-14
Last Update Date:2013-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD63391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty