Provider Demographics
NPI:1154103638
Name:ADAMS AVENUE DENTAL PLLC
Entity type:Organization
Organization Name:ADAMS AVENUE DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA-ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:5300 ADAMS AVE PKWY STE 17
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6966
Mailing Address - Country:US
Mailing Address - Phone:801-479-4580
Mailing Address - Fax:
Practice Address - Street 1:5300 ADAMS AVE PKWY STE 17
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6966
Practice Address - Country:US
Practice Address - Phone:801-479-4580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty