Provider Demographics
NPI:1962091454
Name:HIGHBURY DENTAL MANAGEMENT, LLC
Entity type:Organization
Organization Name:HIGHBURY DENTAL MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MNAGAER
Authorized Official - Prefix:
Authorized Official - First Name:EBONIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-850-3769
Mailing Address - Street 1:325 S HIGLEY RD STE 130
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4703
Mailing Address - Country:US
Mailing Address - Phone:505-850-3769
Mailing Address - Fax:
Practice Address - Street 1:1425 W ELLIOT RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5141
Practice Address - Country:US
Practice Address - Phone:602-536-7072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIGHBURY DENTAL MANAGEMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty