Basic Information
| Provider Information | |||||||||
| NPI: | 1114189487 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DESERT MISSION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHILDREN'S DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9201 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028706060 | ||||||||
| FaxNumber: | 6023315819 | ||||||||
| Practice Location | |||||||||
| Address1: | 9201 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028706060 | ||||||||
| FaxNumber: | 6023315819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 11/09/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HALLMAN | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6028706060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | F0049 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.