Provider Demographics
NPI:1134338973
Name:ARIZONA PERIODONTAL GROUP PLLC
Entity type:Organization
Organization Name:ARIZONA PERIODONTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUJILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-995-5045
Mailing Address - Street 1:1717 W NORTHERN AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5469
Mailing Address - Country:US
Mailing Address - Phone:602-995-5045
Mailing Address - Fax:602-995-3222
Practice Address - Street 1:1717 W NORTHERN AVE
Practice Address - Street 2:STE 104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5469
Practice Address - Country:US
Practice Address - Phone:602-995-5045
Practice Address - Fax:602-995-3222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty