Provider Demographics
NPI:1215680004
Name:SSPDENTAL
Entity type:Organization
Organization Name:SSPDENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRACHI
Authorized Official - Middle Name:
Authorized Official - Last Name:TYAGI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-254-8100
Mailing Address - Street 1:5623 E ASTER DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-4305
Mailing Address - Country:US
Mailing Address - Phone:310-254-8100
Mailing Address - Fax:
Practice Address - Street 1:1618 E BELL RD STE 108
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-2835
Practice Address - Country:US
Practice Address - Phone:602-493-0206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental