Provider Demographics
NPI:1649685207
Name:MARKET STREET DENTAL
Entity type:Organization
Organization Name:MARKET STREET DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOPSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-563-0069
Mailing Address - Street 1:20875 N PIMA RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-9194
Mailing Address - Country:US
Mailing Address - Phone:480-563-0069
Mailing Address - Fax:
Practice Address - Street 1:20875 N PIMA RD STE 105
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-9194
Practice Address - Country:US
Practice Address - Phone:480-563-0069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD075981223G0001X
AZD045161223P0700X
AZD06018124Q00000X
AZH04081124Q00000X
AZD041711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty