Provider Demographics
NPI:1154622249
Name:SOUTHWEST DENTAL PROFESSIONALS PLLC
Entity type:Organization
Organization Name:SOUTHWEST DENTAL PROFESSIONALS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:GROOP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-664-1449
Mailing Address - Street 1:316 W ANGUS RD
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-4989
Mailing Address - Country:US
Mailing Address - Phone:480-390-2060
Mailing Address - Fax:
Practice Address - Street 1:316 W ANGUS RD
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85143-4989
Practice Address - Country:US
Practice Address - Phone:480-390-2060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD07819122300000X
AZD087191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty