Provider Demographics
NPI:1063789816
Name:MODERN DENTAL PROFESSIONALS - ARIZONA PC
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS - ARIZONA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-428-2000
Mailing Address - Street 1:1855 S COUNTRY CLUB DR
Mailing Address - Street 2:STE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6037
Mailing Address - Country:US
Mailing Address - Phone:714-428-2000
Mailing Address - Fax:
Practice Address - Street 1:1855 S COUNTRY CLUB DR
Practice Address - Street 2:STE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6037
Practice Address - Country:US
Practice Address - Phone:714-428-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty