Provider Demographics
NPI:1891875498
Name:PHOENIX PEDIATRIC DENTAL, LLC
Entity Type:Organization
Organization Name:PHOENIX PEDIATRIC DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:PACHECO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-242-5741
Mailing Address - Street 1:6750 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1127
Mailing Address - Country:US
Mailing Address - Phone:602-242-5741
Mailing Address - Fax:602-242-5742
Practice Address - Street 1:6750 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1127
Practice Address - Country:US
Practice Address - Phone:602-242-5741
Practice Address - Fax:602-242-5742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ409926Medicaid
AZ627562Medicaid
AZ570475Medicaid
AZ883737Medicaid
AZ450924Medicaid
AZ796862Medicaid