Provider Demographics
NPI:1588363543
Name:SP DENTAL
Entity type:Organization
Organization Name:SP DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-230-1161
Mailing Address - Street 1:3003 N CENTRAL AVE STE 630
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2905
Mailing Address - Country:US
Mailing Address - Phone:602-230-1161
Mailing Address - Fax:
Practice Address - Street 1:3003 N CENTRAL AVE STE 630
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2905
Practice Address - Country:US
Practice Address - Phone:602-230-1161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-28
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty