Provider Demographics
NPI:1356374714
Name:WESTSIDE DENTAL P.C.
Entity type:Organization
Organization Name:WESTSIDE DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPINE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-849-0477
Mailing Address - Street 1:2330 N 75TH AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85035-1200
Mailing Address - Country:US
Mailing Address - Phone:623-849-0477
Mailing Address - Fax:
Practice Address - Street 1:2330 N 75TH AVE STE 112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85035-1200
Practice Address - Country:US
Practice Address - Phone:623-849-0477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD57861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty