Provider Demographics
NPI:1487792594
Name:FAMILY TOOTH DOCTOR LL, LLC
Entity type:Organization
Organization Name:FAMILY TOOTH DOCTOR LL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-223-0255
Mailing Address - Street 1:4435 E BROADWAY RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2012
Mailing Address - Country:US
Mailing Address - Phone:480-223-0255
Mailing Address - Fax:480-654-0705
Practice Address - Street 1:4435 E BROADWAY RD
Practice Address - Street 2:SUITE 9
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2012
Practice Address - Country:US
Practice Address - Phone:480-223-0255
Practice Address - Fax:480-654-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD42151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty