Provider Demographics
NPI:1952020612
Name:MARKETSIDE STREET DENTAL LLC
Entity type:Organization
Organization Name:MARKETSIDE STREET DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING LEAD
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:PO BOX 734753
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4753
Mailing Address - Country:US
Mailing Address - Phone:623-401-9440
Mailing Address - Fax:
Practice Address - Street 1:20800 W MARKET ST STE 103
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-8040
Practice Address - Country:US
Practice Address - Phone:623-401-9440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-25
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty