Provider Demographics
NPI:1386917839
Name:COMMUNITY DENTAL PARTNERS
Entity type:Organization
Organization Name:COMMUNITY DENTAL PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EOIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-370-1511
Mailing Address - Street 1:3221 N 24TH ST
Mailing Address - Street 2:STE. 23
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7358
Mailing Address - Country:US
Mailing Address - Phone:602-370-1511
Mailing Address - Fax:602-265-4007
Practice Address - Street 1:21321 E OCOTILLO RD
Practice Address - Street 2:BLDG C STE.106
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5996
Practice Address - Country:US
Practice Address - Phone:602-370-1511
Practice Address - Fax:602-265-4007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD50631223G0001X
AZD51101223P0221X
AZD18191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty