Provider Demographics
NPI:1154808749
Name:KIDIATRIC ORTHODONTICS PLLC
Entity type:Organization
Organization Name:KIDIATRIC ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-494-2001
Mailing Address - Street 1:224 W CHANDLER HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-5072
Mailing Address - Country:US
Mailing Address - Phone:480-494-2001
Mailing Address - Fax:
Practice Address - Street 1:224 W CHANDLER HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-5072
Practice Address - Country:US
Practice Address - Phone:480-494-2001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty