Basic Information
| Provider Information | |||||||||
| NPI: | 1881266021 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AZ SPECIALTY DENTAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 CHURCH ST STE 1400 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372192214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156780759 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2835 E BROWN RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852135470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156780759 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2021 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | DASCH | ||||||||
| AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDERRELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5046380303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223X0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.