Provider Demographics
NPI:1306563176
Name:KIDESS DENTAL ASSOCIATES LLC
Entity type:Organization
Organization Name:KIDESS DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING LEAD
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA-ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:7373 N SCOTTSDALE RD STE A220
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-3596
Mailing Address - Country:US
Mailing Address - Phone:480-991-2290
Mailing Address - Fax:
Practice Address - Street 1:7373 N SCOTTSDALE RD STE A220
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85253-3596
Practice Address - Country:US
Practice Address - Phone:480-991-2290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty