Provider Demographics
NPI:1285172551
Name:PREMIER FAMILY DENTAL HOLDINGS LLC
Entity type:Organization
Organization Name:PREMIER FAMILY DENTAL HOLDINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:ONDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-889-9457
Mailing Address - Street 1:3050 E CHANDLER HEIGHTS RD
Mailing Address - Street 2:STE 105
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85290
Mailing Address - Country:US
Mailing Address - Phone:480-279-5611
Mailing Address - Fax:480-279-5610
Practice Address - Street 1:3050 E CHANDLER HEIGHTS RD
Practice Address - Street 2:STE 105
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85290
Practice Address - Country:US
Practice Address - Phone:480-279-5611
Practice Address - Fax:480-279-5610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty