Provider Demographics
NPI:1265896468
Name:DESERT VILLA DENTAL LLC
Entity type:Organization
Organization Name:DESERT VILLA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WA
Authorized Official - Middle Name:N
Authorized Official - Last Name:CHAO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-399-2700
Mailing Address - Street 1:1055 N LA CANADA DR
Mailing Address - Street 2:STE 109
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-3700
Mailing Address - Country:US
Mailing Address - Phone:520-399-2700
Mailing Address - Fax:520-399-4001
Practice Address - Street 1:1055 N LA CANADA DR
Practice Address - Street 2:STE 109
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-3700
Practice Address - Country:US
Practice Address - Phone:520-399-2700
Practice Address - Fax:520-399-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD059861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty