Provider Demographics
NPI:1841536612
Name:AZ LIFETIME DENTISTRY LLC
Entity type:Organization
Organization Name:AZ LIFETIME DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:ELROD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-544-2240
Mailing Address - Street 1:11445 E VIA LINDA STE 2422
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-2655
Mailing Address - Country:US
Mailing Address - Phone:480-544-2240
Mailing Address - Fax:
Practice Address - Street 1:13065 W MCDOWELL RD STE 112
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6439
Practice Address - Country:US
Practice Address - Phone:623-455-6958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty