Provider Demographics
NPI:1972796605
Name:KINDER PEDIATRIC DENTAL SPECIALIST, PLLC
Entity Type:Organization
Organization Name:KINDER PEDIATRIC DENTAL SPECIALIST, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ESSER
Authorized Official - Last Name:DOVE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-644-7124
Mailing Address - Street 1:11442 E BELLS VISITS DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259
Mailing Address - Country:US
Mailing Address - Phone:480-288-5955
Mailing Address - Fax:480-288-4345
Practice Address - Street 1:209 W. APACHE TR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120
Practice Address - Country:US
Practice Address - Phone:480-288-5955
Practice Address - Fax:480-288-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0221X
CA51010261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ456229Medicaid
CAG9398501Medicaid