Provider Demographics
NPI:1164676292
Name:LEGENDS FAMILY DENTAL CENTER
Entity type:Organization
Organization Name:LEGENDS FAMILY DENTAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-561-1991
Mailing Address - Street 1:20241 N 67TH AVE
Mailing Address - Street 2:SUITE A3
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6653
Mailing Address - Country:US
Mailing Address - Phone:623-561-1991
Mailing Address - Fax:
Practice Address - Street 1:20241 N 67TH AVE
Practice Address - Street 2:SUITE A3
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6653
Practice Address - Country:US
Practice Address - Phone:623-561-1991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6891261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental