Provider Demographics
NPI:1952461998
Name:EASTRIDGE FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:EASTRIDGE FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LOVELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-615-8585
Mailing Address - Street 1:9937 E BASELINE RD
Mailing Address - Street 2:STE. 104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-8330
Mailing Address - Country:US
Mailing Address - Phone:480-615-8585
Mailing Address - Fax:480-615-8686
Practice Address - Street 1:9937 E BASELINE RD
Practice Address - Street 2:STE. 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-8330
Practice Address - Country:US
Practice Address - Phone:480-615-8585
Practice Address - Fax:480-615-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty