Provider Demographics
NPI:1134616378
Name:SCOTTSDALE IMPLANT AND COSMETIC DENTISTRY LLC
Entity type:Organization
Organization Name:SCOTTSDALE IMPLANT AND COSMETIC DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PORTIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FREDSTRUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-303-5827
Mailing Address - Street 1:7547 S FRONTIER ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-0130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4910 E GREENWAY RD STE 7
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-1653
Practice Address - Country:US
Practice Address - Phone:480-200-3453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VALLEY IMPLANT CENTERS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009808261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1457874901OtherPROVIDER NPI