Basic Information
| Provider Information | |||||||||
| NPI: | 1154856177 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAVEEN MODERN DENTISTRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3036 W MOHAWK LN | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850273117 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5045 W BASELINE RD STE 135 | ||||||||
| Address2: | |||||||||
| City: | LAVEEN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853397394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022370613 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2017 | ||||||||
| LastUpdateDate: | 04/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | GIRARDI | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 2094812544 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 9657 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.