Provider Demographics
NPI:1962850073
Name:LAVEEN PEDIATRIC DENTAL PARTNERS, LLP
Entity Type:Organization
Organization Name:LAVEEN PEDIATRIC DENTAL PARTNERS, LLP
Other - Org Name:LAVEEN KID'S DENTIST AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:E
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-883-8649
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8656
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:5235 W. BASELINE RD, STE 187
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339
Practice Address - Country:US
Practice Address - Phone:602-883-8649
Practice Address - Fax:602-744-8778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty