Provider Demographics
NPI:1295281525
Name:WEST VALLEY ENDODONTICS AND ORAL SURGERY INC
Entity type:Organization
Organization Name:WEST VALLEY ENDODONTICS AND ORAL SURGERY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:H
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-418-1597
Mailing Address - Street 1:14122 W MCDOWELL RD
Mailing Address - Street 2:201
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2503
Mailing Address - Country:US
Mailing Address - Phone:623-444-4521
Mailing Address - Fax:623-444-8304
Practice Address - Street 1:14122 W. MCDOWELL RD.
Practice Address - Street 2:201
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:623-444-4521
Practice Address - Fax:623-444-8304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD52151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5694444Medicaid