Provider Demographics
NPI:1396932034
Name:ARIZONA DENTAL OMNICARE, LLC
Entity type:Organization
Organization Name:ARIZONA DENTAL OMNICARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:SLEPAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-269-5914
Mailing Address - Street 1:4805 W THOMAS RD
Mailing Address - Street 2:STE A
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-4050
Mailing Address - Country:US
Mailing Address - Phone:602-269-5914
Mailing Address - Fax:602-269-0083
Practice Address - Street 1:4805 W THOMAS RD
Practice Address - Street 2:STE A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-4050
Practice Address - Country:US
Practice Address - Phone:602-269-5914
Practice Address - Fax:602-269-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty