Provider Demographics
NPI:1972930147
Name:SCOTTSDALE PROSTHODONTICS AND FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SCOTTSDALE PROSTHODONTICS AND FAMILY DENTISTRY
Other - Org Name:SMILE DESIGN SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHREEDEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:THULASIDAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:480-815-5223
Mailing Address - Street 1:34597 N 60TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85266-5241
Mailing Address - Country:US
Mailing Address - Phone:480-488-9655
Mailing Address - Fax:480-575-1130
Practice Address - Street 1:34597 N 60TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85266-5241
Practice Address - Country:US
Practice Address - Phone:480-488-9655
Practice Address - Fax:480-575-1130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD07677122300000X, 1223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty