Basic Information
Provider Information
NPI: 1528347812
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: UPTON
FirstName: CELINE
MiddleName: RENEE
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2702 N 3RD ST
Address2: STE. 4020
City: PHOENIX
State: AZ
PostalCode: 850041130
CountryCode: US
TelephoneNumber: 6023233345
FaxNumber: 6023233399
Practice Location
Address1: 6601 W THOMAS RD
Address2:  
City: PHOENIX
State: AZ
PostalCode: 850335700
CountryCode: US
TelephoneNumber: 6022437277
FaxNumber: 6232479742
Other Information
ProviderEnumerationDate: 08/04/2011
LastUpdateDate: 06/27/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X008860AZY Dental ProvidersDentist 

ID Information
IDTypeStateIssuerDescription
6054601CADENTAL LICENSEOTHER
00886005AZ MEDICAID


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