Provider Demographics
NPI:1922123363
Name:WSG DENTAL DEVELOPMENT, LLC
Entity Type:Organization
Organization Name:WSG DENTAL DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR AND INSURANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:FAWNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-944-0073
Mailing Address - Street 1:2323 W MESCAL ST STE 205
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4764
Mailing Address - Country:US
Mailing Address - Phone:602-944-0073
Mailing Address - Fax:602-944-0371
Practice Address - Street 1:5577 N ORACLE RD STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3878
Practice Address - Country:US
Practice Address - Phone:520-293-2267
Practice Address - Fax:520-293-4008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5988122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty