Provider Demographics
NPI:1639913692
Name:QUEEN CREEK IMPLANTS & PERIODONTICS
Entity type:Organization
Organization Name:QUEEN CREEK IMPLANTS & PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENAVIDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-247-6558
Mailing Address - Street 1:22363 E DOMINGO RD STE 103
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-0353
Mailing Address - Country:US
Mailing Address - Phone:480-247-6558
Mailing Address - Fax:480-275-2404
Practice Address - Street 1:22363 E DOMINGO RD STE 103
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-0353
Practice Address - Country:US
Practice Address - Phone:480-247-6558
Practice Address - Fax:480-275-2404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-24
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty