Basic Information
Provider Information | |||||||||
NPI: | 1487842423 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUNDANCE DENTAL GROUP, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUNDANCE DENTAL GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 920050 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753920050 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148458890 | ||||||||
FaxNumber: | 3039520892 | ||||||||
Practice Location | |||||||||
Address1: | 825 S WATSON RD STE 101 | ||||||||
Address2: |   | ||||||||
City: | BUCKEYE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853263435 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6233867319 | ||||||||
FaxNumber: | 6233867609 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2007 | ||||||||
LastUpdateDate: | 04/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PARKER | ||||||||
AuthorizedOfficialFirstName: | DON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
AuthorizedOfficialTelephone: | 6029036646 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: | 04/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.