Provider Demographics
NPI:1982248084
Name:WESTBROOK DENTAL CENTER, P.A.
Entity type:Organization
Organization Name:WESTBROOK DENTAL CENTER, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-972-6137
Mailing Address - Street 1:9276 W UNION HILLS DR STE A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-8206
Mailing Address - Country:US
Mailing Address - Phone:623-972-6137
Mailing Address - Fax:623-972-6334
Practice Address - Street 1:9276 W UNION HILLS DR STE A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8206
Practice Address - Country:US
Practice Address - Phone:623-972-6137
Practice Address - Fax:623-972-6334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-31
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1629075130OtherINDIVIDUAL NPI
AZ4489OtherLICENSE