Provider Demographics
NPI:1215610555
Name:MOON VALLEY DENTAL LLC
Entity type:Organization
Organization Name:MOON VALLEY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:EICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-310-2582
Mailing Address - Street 1:8035 S 27TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-7063
Mailing Address - Country:US
Mailing Address - Phone:480-760-5528
Mailing Address - Fax:
Practice Address - Street 1:13825 N 7TH ST STE C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-4342
Practice Address - Country:US
Practice Address - Phone:602-993-9912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental