Provider Demographics
NPI:1104590728
Name:STETSON VILLAGE DENTAL LLC
Entity type:Organization
Organization Name:STETSON VILLAGE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTORY
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GASKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:3870 W HAPPY VALLEY RD STE 154
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3296
Mailing Address - Country:US
Mailing Address - Phone:623-533-4895
Mailing Address - Fax:
Practice Address - Street 1:3870 W HAPPY VALLEY RD STE 154
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-3296
Practice Address - Country:US
Practice Address - Phone:623-533-4895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty