Basic Information
| Provider Information | |||||||||
| NPI: | 1376200261 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURPRISE MODERN DENTISTRY LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 920050 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753920050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458892 | ||||||||
| FaxNumber: | 3039520892 | ||||||||
| Practice Location | |||||||||
| Address1: | 13733 N PRASADA PKWY STE 108 | ||||||||
| Address2: | |||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853888007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237773329 | ||||||||
| FaxNumber: | 6239002676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2021 | ||||||||
| LastUpdateDate: | 11/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6237773329 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | 11/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.