Provider Demographics
NPI:1992364319
Name:HEARTLAND DENTAL CARE OF ARIZONA, PC
Entity Type:Organization
Organization Name:HEARTLAND DENTAL CARE OF ARIZONA, PC
Other - Org Name:LAKESIDE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:4920 S ALMA SCHOOL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-5547
Mailing Address - Country:US
Mailing Address - Phone:807-396-4044
Mailing Address - Fax:480-590-6481
Practice Address - Street 1:4920 S ALMA SCHOOL RD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-5547
Practice Address - Country:US
Practice Address - Phone:602-612-9711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-10
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty