Provider Demographics
NPI:1770208498
Name:DAN RODDA, DDS, PLLC
Entity type:Organization
Organization Name:DAN RODDA, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODDA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-525-4642
Mailing Address - Street 1:449 W WULFENITE RD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86005-6836
Mailing Address - Country:US
Mailing Address - Phone:928-525-4642
Mailing Address - Fax:
Practice Address - Street 1:15255 N 40TH ST STE 141
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4682
Practice Address - Country:US
Practice Address - Phone:928-525-4642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental