Provider Demographics
NPI:1972097392
Name:LYDIAN DENTAL QUEEN CREEK, LLC
Entity type:Organization
Organization Name:LYDIAN DENTAL QUEEN CREEK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUCKHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-445-9188
Mailing Address - Street 1:21295 S ELLSWORTH LOOP RD STE 103
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-9867
Mailing Address - Country:US
Mailing Address - Phone:480-445-9188
Mailing Address - Fax:480-526-8177
Practice Address - Street 1:21295 S ELLSWORTH LOOP RD STE 103
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-9867
Practice Address - Country:US
Practice Address - Phone:480-445-9188
Practice Address - Fax:480-526-8177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0092701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty