Provider Demographics
NPI:1588922272
Name:IVY 2 DENTAL, PLLC
Entity type:Organization
Organization Name:IVY 2 DENTAL, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:UMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:IMTIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-328-2886
Mailing Address - Street 1:23374 W YUMA RD
Mailing Address - Street 2:STE. 102
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-3118
Mailing Address - Country:US
Mailing Address - Phone:978-328-2886
Mailing Address - Fax:
Practice Address - Street 1:23478 N. SUNDANCE PKWY WEST, SUITE 103
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-3118
Practice Address - Country:US
Practice Address - Phone:623-444-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ72561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty