Provider Demographics
NPI:1669958781
Name:PLAZA FAMILY DENTAL INC
Entity type:Organization
Organization Name:PLAZA FAMILY DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILDUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-391-4107
Mailing Address - Street 1:7205 E SOUTHERN AVE STE A-122
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-2790
Mailing Address - Country:US
Mailing Address - Phone:602-391-4107
Mailing Address - Fax:
Practice Address - Street 1:9145 W THUNDERBIRD RD STE H105
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4820
Practice Address - Country:US
Practice Address - Phone:623-979-7477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009244122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty