Provider Demographics
NPI:1013346857
Name:DENTISTRY AT 35TH AVENU
Entity Type:Organization
Organization Name:DENTISTRY AT 35TH AVENU
Other - Org Name:DBA FLOSS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-581-5532
Mailing Address - Street 1:18635 N 35TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027
Mailing Address - Country:US
Mailing Address - Phone:623-581-5532
Mailing Address - Fax:623-236-9360
Practice Address - Street 1:18635 N 35TH AVENUE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027
Practice Address - Country:US
Practice Address - Phone:623-581-5532
Practice Address - Fax:623-236-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0082801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty