Provider Demographics
NPI:1942315478
Name:GILBERT DENTAL CENTER
Entity Type:Organization
Organization Name:GILBERT DENTAL CENTER
Other - Org Name:GILBERT DENTAL CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:WALKER
Authorized Official - Last Name:BOLLWINKEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-892-5089
Mailing Address - Street 1:1400 N GILBERT RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2328
Mailing Address - Country:US
Mailing Address - Phone:480-892-5089
Mailing Address - Fax:480-892-4236
Practice Address - Street 1:1400 N GILBERT RD
Practice Address - Street 2:SUITE A
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2328
Practice Address - Country:US
Practice Address - Phone:480-892-5089
Practice Address - Fax:480-892-4236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTIN