Provider Demographics
NPI:1891907630
Name:ACACIA DENTAL
Entity type:Organization
Organization Name:ACACIA DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-831-7775
Mailing Address - Street 1:1321 E KRISTA WAY
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1658
Mailing Address - Country:US
Mailing Address - Phone:480-831-7775
Mailing Address - Fax:480-831-8108
Practice Address - Street 1:7517 S. MCCLINTOCK DR.
Practice Address - Street 2:SUITE 1006
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-5011
Practice Address - Country:US
Practice Address - Phone:480-831-7775
Practice Address - Fax:480-831-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4342122300000X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No122300000XDental ProvidersDentistGroup - Single Specialty