Provider Demographics
NPI:1639677115
Name:INNOVATIVE DENTAL GROUP, PLLC
Entity type:Organization
Organization Name:INNOVATIVE DENTAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMIAEI-ASADI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:520-353-3002
Mailing Address - Street 1:5209 N ORACLE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3707
Mailing Address - Country:US
Mailing Address - Phone:520-353-3002
Mailing Address - Fax:520-293-3723
Practice Address - Street 1:5209 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3707
Practice Address - Country:US
Practice Address - Phone:520-353-3002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0084831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty