Provider Demographics
NPI:1932278025
Name:CORONADO DENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:CORONADO DENTAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENDRIX
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-461-8683
Mailing Address - Street 1:610 N ALMA SCHOOL ROAD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-3687
Mailing Address - Country:US
Mailing Address - Phone:480-461-8683
Mailing Address - Fax:480-964-4171
Practice Address - Street 1:610 N ALMA SCHOOL ROAD
Practice Address - Street 2:SUITE 4
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-3687
Practice Address - Country:US
Practice Address - Phone:480-461-8683
Practice Address - Fax:480-964-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5032122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ188286Medicaid
AZ46654101Medicaid
AZ49124101Medicaid