Provider Demographics
NPI:1184081804
Name:ERIC R WIITALA DDS PLLC
Entity type:Organization
Organization Name:ERIC R WIITALA DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:WIITALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-657-6981
Mailing Address - Street 1:9755 NORTH 90TH STREET
Mailing Address - Street 2:SUITE B250
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5076
Mailing Address - Country:US
Mailing Address - Phone:480-657-6981
Mailing Address - Fax:
Practice Address - Street 1:9755 NORTH 90TH STREET
Practice Address - Street 2:SUITE B250
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5076
Practice Address - Country:US
Practice Address - Phone:480-657-6981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD053881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty