Provider Demographics
NPI:1740484278
Name:PRIDE DENTAL GROUP PLLC
Entity type:Organization
Organization Name:PRIDE DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-946-0404
Mailing Address - Street 1:3226 N MILLER RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6930
Mailing Address - Country:US
Mailing Address - Phone:480-946-0404
Mailing Address - Fax:480-946-0789
Practice Address - Street 1:3226 N MILLER RD STE 3
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6930
Practice Address - Country:US
Practice Address - Phone:480-946-0404
Practice Address - Fax:480-946-0789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09081901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty