Provider Demographics
NPI:1770307704
Name:AVELLE LICHFIELD ORTHO LLC
Entity type:Organization
Organization Name:AVELLE LICHFIELD ORTHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:253-283-2747
Mailing Address - Street 1:4365 E PECOS RD STE 136
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-8053
Mailing Address - Country:US
Mailing Address - Phone:480-712-9595
Mailing Address - Fax:
Practice Address - Street 1:14140 W INDIAN SCHOOL RD STE B1
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-9293
Practice Address - Country:US
Practice Address - Phone:480-712-9595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty