Provider Demographics
NPI:1255626651
Name:VALLEY ORTHODONTIC GROUP LLC
Entity type:Organization
Organization Name:VALLEY ORTHODONTIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GROB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:520-490-7864
Mailing Address - Street 1:522 W. FIRST ST
Mailing Address - Street 2:UNIT 101
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281
Mailing Address - Country:US
Mailing Address - Phone:520-490-7864
Mailing Address - Fax:520-297-9410
Practice Address - Street 1:522 W. FIRST ST
Practice Address - Street 2:UNIT 101
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281
Practice Address - Country:US
Practice Address - Phone:520-490-7864
Practice Address - Fax:520-297-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ33171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty