Provider Demographics
NPI:1932545456
Name:CASA GRANDE PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:CASA GRANDE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:520-421-1400
Mailing Address - Street 1:1968 N PEART RD STE 19
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-2497
Mailing Address - Country:US
Mailing Address - Phone:520-421-1400
Mailing Address - Fax:520-421-1444
Practice Address - Street 1:1968 N PEART RD STE 19
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2497
Practice Address - Country:US
Practice Address - Phone:520-421-1400
Practice Address - Fax:520-421-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD054101223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ587800Medicaid