Provider Demographics
NPI:1659836369
Name:DENTAL AND BRACES ROOSEVELT PLLC
Entity type:Organization
Organization Name:DENTAL AND BRACES ROOSEVELT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-714-8203
Mailing Address - Street 1:1515 N GILBERT RD STE 107-131
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2318
Mailing Address - Country:US
Mailing Address - Phone:602-714-8203
Mailing Address - Fax:
Practice Address - Street 1:1602 E ROOSEVELT ST STE 301
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3678
Practice Address - Country:US
Practice Address - Phone:602-888-2884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11901383OtherDENTAL OFFICE