Provider Demographics
NPI:1831731587
Name:MARICOPA FAMILY DENTAL LLC
Entity type:Organization
Organization Name:MARICOPA FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:20046 N. JOHN WAYNE PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139
Mailing Address - Country:US
Mailing Address - Phone:520-316-6100
Mailing Address - Fax:520-568-7312
Practice Address - Street 1:20046 N. JOHN WAYNE PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139
Practice Address - Country:US
Practice Address - Phone:520-316-6100
Practice Address - Fax:520-568-7312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty