Provider Demographics
NPI:1336535152
Name:KIDZ R KOOL
Entity Type:Organization
Organization Name:KIDZ R KOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-572-5777
Mailing Address - Street 1:7505 W DEER VALLEY RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2107
Mailing Address - Country:US
Mailing Address - Phone:623-572-5777
Mailing Address - Fax:623-572-7288
Practice Address - Street 1:7505 W DEER VALLEY RD
Practice Address - Street 2:SUITE 110
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2107
Practice Address - Country:US
Practice Address - Phone:623-572-5777
Practice Address - Fax:623-572-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ390493-004Medicaid