Provider Demographics
NPI:1922330141
Name:PROMENADE DENTAL PLLC
Entity Type:Organization
Organization Name:PROMENADE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WEI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-802-8188
Mailing Address - Street 1:4905 S ALMA SCHOOL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-5503
Mailing Address - Country:US
Mailing Address - Phone:480-802-8188
Mailing Address - Fax:
Practice Address - Street 1:4905 S ALMA SCHOOL RD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-5503
Practice Address - Country:US
Practice Address - Phone:480-802-8188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEWPORT DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-13
Last Update Date:2010-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty