Provider Demographics
NPI:1942744081
Name:ARIZONA DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:ARIZONA DENTAL PROFESSIONALS, PC
Other - Org Name:SAN TAN MOUNTAIN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:545 E HUNT HWY
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 E HUNT HWY
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143
Practice Address - Country:US
Practice Address - Phone:480-476-9180
Practice Address - Fax:480-476-9186
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-08
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty