Provider Demographics
NPI:1740532654
Name:AZ DENTAL SPECIALTY GROUP
Entity type:Organization
Organization Name:AZ DENTAL SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:BASSETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:623-435-2300
Mailing Address - Street 1:9035 N 43RD AVE
Mailing Address - Street 2:STE. C
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051
Mailing Address - Country:US
Mailing Address - Phone:623-435-2300
Mailing Address - Fax:623-435-1700
Practice Address - Street 1:9035 N 43RD AVE
Practice Address - Street 2:STE. C
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051
Practice Address - Country:US
Practice Address - Phone:623-435-2300
Practice Address - Fax:623-435-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF000453122300000X
AZ83281223P0300X
AZ21761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty