Provider Demographics
NPI:1124858154
Name:PEORIA DENTISTRY
Entity type:Organization
Organization Name:PEORIA DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-363-2145
Mailing Address - Street 1:20470 N LAKE PLEASANT RD STE 105
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9708
Mailing Address - Country:US
Mailing Address - Phone:623-825-7003
Mailing Address - Fax:623-825-0076
Practice Address - Street 1:20470 N LAKE PLEASANT RD STE 105
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9708
Practice Address - Country:US
Practice Address - Phone:623-825-7003
Practice Address - Fax:623-825-0076
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIVADENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty