Provider Demographics
NPI:1306277918
Name:HERMOSA DENTAL AND ORTHODONTICS GROUP LLC
Entity type:Organization
Organization Name:HERMOSA DENTAL AND ORTHODONTICS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RASOUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SALIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-242-0550
Mailing Address - Street 1:3415 W GLENDALE AVE
Mailing Address - Street 2:30
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-8386
Mailing Address - Country:US
Mailing Address - Phone:602-242-0550
Mailing Address - Fax:602-242-4965
Practice Address - Street 1:3415 W GLENDALE AVE
Practice Address - Street 2:30
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-8386
Practice Address - Country:US
Practice Address - Phone:602-242-0550
Practice Address - Fax:602-242-4965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD68761223P0300X
AZD84031223S0112X
AZD83691223X0400X
AZD50671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty