Provider Demographics
NPI:1801125786
Name:ARIZONA DENTAL SPECIALTY GROUP PLLC
Entity type:Organization
Organization Name:ARIZONA DENTAL SPECIALTY GROUP PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HAASLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-626-5437
Mailing Address - Street 1:PO BOX 80220
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0220
Mailing Address - Country:US
Mailing Address - Phone:602-626-5437
Mailing Address - Fax:
Practice Address - Street 1:3722 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7508
Practice Address - Country:US
Practice Address - Phone:602-626-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD58301223G0001X
AZD58021223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty