Provider Demographics
NPI:1427325273
Name:MODERN DENTAL PROFESSIONALS-ARIZONA PC
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS-ARIZONA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-428-2000
Mailing Address - Street 1:9230 W NORTHERN AVE
Mailing Address - Street 2:106
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-1100
Mailing Address - Country:US
Mailing Address - Phone:626-696-3990
Mailing Address - Fax:623-877-8831
Practice Address - Street 1:9230 W NORTHERN AVE
Practice Address - Street 2:106
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-1100
Practice Address - Country:US
Practice Address - Phone:626-696-3990
Practice Address - Fax:623-877-8831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty